Patient Information Form

Please correct the errors described below.
(Please provide a copy of the ins card/cards)
(Please provide Photo I.D.)
(Please provide Photo I.D.)

Missed Appointment Policy:

Permission to bring patient in for appointments:

For the safety of your child, please list the people you give permission to bring your child into the office for their appointments. We will ask for a photo I.D. at the time of the appointment to confirm they are on this list.

(This list may be updated at any time. If you want to update it, please request a new form.)

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AUTHORIZATION FOR RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS

In order to process claims for benefits, I authorize Rocky Mountain Pediatrics, P.C. to release any medical information (medical history, symptoms, treatment, examination, results or diagnosis) regarding me/my child to the Administrator of my insurance plan or its representatives. I also authorize payment of medical benefits directly to Rocky Mountain Pediatrics, P.C. A photocopy of this authorization shall be considered as effective and valid as the original.

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.

Your information will be encrypted.

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