Patient Registration Form

Patient Information

Name

Date of Birth

Address

City

State

Zip

Social Security Number

Home Phone

Brothers and Sisters

Guarantor (RESPONSIBLE PERSON) Information

Name

Date of Birth

Address

City

State

Zip

SS#

Home Phone

Work Phone

Cell Phone

Employer Name

Email address

Health Insurance Information

Complete this section in its entirety, if we are unable to bill your insurance company we may have to bill you directly.
Please be sure to give your insurance card to the front desk.

Primary Insurance

Primary Insurance Name

ID #

Group #

Name of Insured

Insured's Relationship to Patient

Insured's DOB

SS#

Secondary Insurance

Primary Insurance Name

ID #

Group #

Name of Insured

Insured's Relationship to Patient

Insured's DOB

SS#

Emergency Contact Information

Add Name

Authorization

May we leave the following types of messages at your home, work, cell or emergency contact

1. Appointment Changes

Yes No

2. Test Results

Yes No

3. Prescription Info

Yes No

4. Billing Answers

Yes No

5. Health Advisor

Yes No

I hereby authorize the physician(s) of Phoenix Pediatrics Ltd, to provide medical treatment to the patient on this form.

I hereby authorize third parties to pay directly to the physicians(s) any insurance benefits due for services rendered on behalf of the named patient.

I authorize the physician(s) to furnish my insurance company and / or third party payers (or their representatives), any medical information necessary to process our insurance claims

I understand that I am responsible for payment of all charges for medical services rendered to the named patient.

I hereby authorize the treating person(s) to take photographic pictures of the treated areas when medically necessary and I understand that these pictures will be safety stored in the named patient's clinical record.

As required by the Privacy Regulations, I hereby acknowledge that I have reviewed a current copy of "Notice of Privacy Policy". I have read the Privacy policy and understand my rights contained in the notice.

By way of my signature, I provide Phoenix Pediatrics Ltd, my authorization and consent to use and disclose protected healthcare information for the purposes of treatment, payment and healthcare operations described in the Privacy Policy.

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

Relationship to Patient

Your information will be encrypted.