Patient Renewal Form

Add Another Child

Mailing Address:

Primary Phone:

Parent/Guardian:

DOB:

Relationship to patient:

Address (if different from patients):

Phone (if different from primary):

Email:

Primary Insurance

Policy Holder's Name:

DOB:

Insurance Carrier:

ID#:

Group #:

Employer:

Secondary Insurance

Policy Holder's Name:

DOB:

Insurance Carrier:

ID#:

Group#:

Employer:

Preferred method of receiving appointment reminders or office notices:

Cell Phone Home Phone Work Phone Patient Portal

Preferred method of receiving statements or billing notices:

Patient Portal Mail

Pharmacy:

Due to HIPAA regulations, We will not release any information to any person unless otherwise listed in the section below:

Add another person

I hereby authorize SWEETWATER PEDIATRICS P.C. to apply for benefits on my behalf for services rendered. The information I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information, for this or any related claim to my insurance company in order to determine these benefits payable. I request that payment of authorized benefits be made payable to SWEETWATER PEDIATRICS P.C. I authorize any treatment considered necessary for the patient. (Consent for Treatment)

1. We participate with most insurance plans. By contract, covered charges will be paid directly to us.

2. Participants are responsible for their co-payments at the time of service.

3. Insurance participants are required to pay in full for charges incurred (Deductible, Co-Insurance). As a courtesy, we will submit the insurance form on your behalf requesting that payment be made directly to us for reimbursement.

4. A $25.00 fee will be charged to all patients for any returned checks.

5. I understand that I am financially responsible for any non-covered and/or denied charges incurred on my behalf and that it is my responsibility to know my insurance coverage guidelines.

6. A copy of this agreement may be used in place of the original.

7. Self-Pay patients must pay a minimum of $75, if paying in full we offer 20% discount at the of service.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

I have been presented with a copy of Sweetwater Pediatric’s ‘Notice of Privacy Policies’, detailing how my information may be used and disclosed as permitted under federal and state law. I understand the contents of the notice, and, subject to the following restriction(s) concerning my personal medical information, I agree to the disclosures named in the Notice

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

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