Patient Registration

Cell Number (Text Reminder)

Carrier Network

** If patient is 14 or older, patient's cell number

Preferred Name

Sex

Male Female

Social Security

Last Name

First Name

Middle

Date of Birth

Street Address

Apt. Number

City

State

Zip

Home Phone

Ethnicity

Race

Language

Pharmacy

Pharmacy Address

MOTHER

Last Name

First Name

Middle

Date of Birth

Social Security Number

Street Address

Apt. Number

City

State

Zip

Home Phone

Cell Phone

Work Phone

Employer

FATHER

Last Name

First Name

Middle

Date of Birth

Social Security Number

Street Address

Apt. Number

City

State

Zip

Home Phone

Cell Phone

Work Phone

Employer

Insurance Information

Primary Insurance

Member ID

Subscriber Name

Group Number

Effective Date

Subscriber Date of Birth

Subscriber SSN

Secondary Insurance

Member ID

Subscriber Name

Group Number

Effective Date

Subscriber Date of Birth

Subscriber SSN

Emergency Contact

Home Phone

Cell Phone

Responsible Party Signature

Date

NON-COVERED SERVICES WAIVER

PATIENT NAME:

D.O.B:

PATIENT NAME:

D.O.B:

PATIENT NAME:

D.O.B:

PATIENT NAME:

D.O.B:

NON-COVERED SERVICES STATEMENT: If you have any questions about whether or not a particular service is covered by your insurance or the amount of services being rendered please contact your insurance company. Depending on your health benefits contract there may be some services which may not be covered by your insurance. You will be expected to pay for these services in full following notification from your insurance carrier. As your child's provider, we will order only the test(s) and treatments) that we feel are necessary for your child's care.

MEDICAID: I understand that if I do not have a Medicaid referral from my assigned PM on the date of service, I will be responsible for any charges incurred.

EXAMPLES OF POSSIBLE NON-COVERED SERVICES FOR PREVENTATIVE (ROUTINE) CARE WHICH MAY BE PROVIDED TODAY BY YOUR PHYSICIAN AND/OR ACTON ROAD PEDIATRICS STAFF ARE LISTED BELOW:

PHYSICIAN SERVICE: Preventative Care Physician Fee (Well Child Visit), Hearing and Vision Screenings

ADDITIONAL TREATMENTS: Issues addressed during a routine visit that would constitute an additional office visit charge.

LABS: CBC/Hematocrit/Blood Draw Fee, Urinalysis and Cholesterol

VACCINES: Vaccines/Antibiotic Injections/Vaccine Administration

OTHER: Allergy testing including lab charges, Developmental Testing and any other possible non-covered service

I have read this policy and agree to pay for all rendered services including those listed above and those that are not that are not covered by my insurance contract as indicated by my signature for each visit my child incurs.

CONSENT FOR TREATMENT: I the undersigned, consent to the care and treatment by the attending physician, her associates, or assistants.
I have reviewed the Policy and Procedures for Acton Road Pediatrics, LLC and agree to the NO SHOW/CANCELLATION POLICY which carries a fee of $25.00.
I understand that there will be a fee for form completion, blue forms, copies of medical records.

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

Patient/Parent/Guardian Signature

Date

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