Patient Information Form

Date

Doctor

Primary Spoken Language

Add Additional Child

Street Address

City

State

Zip Code

Primary Email

Activate Patient Portal

Yes No

Add Additional Parents

INSURANCE:

Please present insurance card for copying. Primary Insurance is through the parent whose birthday occurs first in the calendar year

Primary

Name of Insured & relationship to patient

Policy ID / Group ID

Secondary

Name of Insured & relationship to patient

Policy ID / Group ID

IN CASE OF AN EMERGENCY CONTACT: (Other than parent)

Name

Phone

Relationship

The information provided is confidential and is intended only for the use of Berkeley Pediatric Medical Group

I acknowledge receipt of Berkeley Pediatric Medical Group Financial Policy

I hereby authorize insurance payment be made directly to Berkeley Pediatric Medical Group for surgical or medical benefits. The doctors of Berkeley Pediatric Medical Group and any doctors, hospitals or agents they may designate, have our permission to provide medical and surgical care for our child in our absence.

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.

Signature

Date

Number

Your information will be encrypted.