Bruckner Krasnoff Lederer Marshall Sevran Chan Inc. ⠀ ⠀Pediatric Office on Balboa Blvd

First Name

Middle Name

Last Name

Preferred Name

DOB

SSN

Preferred Language

Gender Identity

Please click to add another Patient

*Add another patient

*Please only add your children who share the same legal guardians, insurance, and contact information.
Otherwise, please fill out a separate form for each child.

Physical Address

Street

City

State

Zip

Mailing Address

Mailing Address Same as Physical Address

Yes No

Street

City

State

Zip

Legal Guardian 1

First Name

Middle Name

Last Name

DOB

SSN

Relationship

Spouse's Name

Employer

Occupation

Primary Phone

This is a mobile phone

Work Phone

This is a mobile phone

Physical Address Same as Patient

Yes No

Mailing Address Same as Patient

Yes No

Physical Address

Street

City

State

Zip

Mailing Address

Street

City

State

Zip

Legal Guardian 2

First Name

Middle Name

Last Name

DOB

SSN

Relationship

Spouse's Name

Employer

Occupation

Primary Phone

This is a mobile phone

Work Phone

This is a mobile phone

Physical Address Same as Patient

Yes No

Mailing Address Same as Patient

Yes No

Physical Address

Street

City

State

Zip

Mailing Address

Street

City

State

Zip

Billing

Responsible Party

Patient Legal Guardian 1 Legal Guardian 2 Other

What email address is preferred for billing e-statements?

If you are not the above responsible party the office will need authorization from that party. Please have them fill out this form and return to the office.

Legal Information

Custodial Parent

If parents are divorced or separated, who has custody?

Legal Restrictions

Are there any legal restrictions that would restrict the noncustodial parent from consenting to medical treatment for the child or from obtaining information about the child’s medical treatment?

Yes No

If yes, please provide legal documents stating restrictions

Legal documents:
Please bring to your visit or email them to info@balboapediatrics.com

**Emergency Contact (different than legal guardians)**

Name

Relationship

Phone

This is a mobile phone

Insurance Primary Carrier

Do you have medical insurance?

Yes No

Carrier

Policy Holder Name

DOB

SSN

Employer

Group

Insurance Secondary Carrier

Do you have a secondary insurance provider?

Yes No

Carrier

Policy Holder Name

DOB

SSN

Employer

Group

Signature

I request that payment of authorized commercial insurance benefits be made to [Provide doctor name below] for any service furnished to me or my dependent by Balboa Pediatrics’ providers. I authorize [ Provide doctor name below ] to release medical information which may be required by my insurance carrier to determine payment for services rendered. I further understand that I am responsible to pay certain amounts due the physician at the time of service. These amounts could include annual administrative fees, annual deductibles, copayments, charges denied as not covered by my commercial insurance carrier, and charges denied for services determined as not medically necessary. I further understand any fees associated with collecting reimbursement on my account, I will be responsible for paying all of those fees.

Select Primary Care Physician(s)

Laura Bruckner, MD, FAAP

Andrew Krasnoff, MD, FAAP

Helen Lederer, MD, FAAP

Catherine Marshall, MD, FAAP

Sloane Sevran, MD, FAAP

Daniel Bruckner, MD, FAAP

Miriam Chan, MD, FAAP

Ofir Mekel, MD, FAAP

Julia Bruckner, DO, FAAP

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

Relationship

Parent/Guardian Signature

Your information will be encrypted.

Bruckner Krasnoff Lederer Marshall Sevran Chan Inc. ⠀ ⠀Pediatric Office on Balboa Blvd

Physical Address

Mailing Address

Legal Guardian 1

Physical Address

Mailing Address

Legal Guardian 2

Physical Address

Mailing Address

Billing

Legal Information

Legal Restrictions

Legal documents: Please bring to your visit or email them to info@balboapediatrics.com

Emergency Contact (different than legal guardians)

Insurance Primary Carrier

Insurance Secondary Carrier

Signature

Legal documents:
Please bring to your visit or email them to info@balboapediatrics.com

**Emergency Contact (different than legal guardians)**