Patient Information Form

Date

Primary Language Spoken

LIST ALL CHILDREN IN THE FAMILY

Add Child

Home Street Address

City

State

ZIP Code

Children live with

Parent/Guardian #1 Parent/Guardian #2 Both

PARENT/LEGAL GUARDIAN RESPONSIBLE FOR PATIENT'S FINANCIAL OBLIGATIONS

PARENT/LEGAL GUARDIAN #1 (OR PATIENT IF 18 YEARS OR OLDER)

First Name

Middle Name

Last Name

Relationship to Patient

Social Security #

Date of Birth

Home Phone

Cell Phone

Email address

Street Address (if different from above)

City

State

Zip

Employer Name

(If not working, please indicate N/A.)

Occupation

Address

City

State

Zip Code

Work Phone (including extension)

PARENT/LEGAL GUARDIAN #2

First Name

Middle Name

Last Name

Relationship to Patient

Social Security #

Date of Birth

Home Phone

Cell Phone

Email address

Street Address (if different from above)

City

State

Zip

Employer Name

Occupation

Address

City

State

Zip Code

Work Phone (including extension)

NEAREST RELATIVE OR EMERGENCY CONTACT INFORMATION

First Name

Last Name

Relationship to Patient

Home Phone

Cell Phone

Referred By

PHARMACY INFORMATION

Pharmacy Name

Phone Number

Address

City

State

Zip Code

HEALTH INSURANCE INFORMATION

Insurance Company

Insurance Company Phone #

Subscriber's Name

Subscriber's Employer

Subscriber's Date of Birth

Subscriber's Social Security #

ID/Policy #

Group #

Effective Date

ASSIGNMENT OF BENEFITS AND AUTHORIZATIONS

I hereby authorize and direct my insurance company to make payments directly to the providers of WEST BROWARD PEDIATRICS, benefits allowable otherwise payable to me and/or my dependents. I understand that I am responsible for charges not paid under this Assignment. This Authorization will remain in effect until rescinded by myself in writing. I further permit a copy of this Authorization be used in place of the original. This Authorization is to apply to all claims submitted by the providers of WEST BROWARD PEDIATRICS. I hereby authorize the providers to release any information required in the course of the examination or treatment.

To avoid misunderstandings regarding medical insurance, all patients should understand that all professional services rendered are charged directly to the patient and that all patients are personally responsible for payment of fees. As a courtesy, we will prepare all necessary forms to help you obtain benefits from insurance companies. We do not render our services on the basis that insurance companies will pay our fees. If your insurance company does not cover the fees in full, the balance is due in full and payable by you.

A $10.00 Administrative Fee, due to processing services will be applied to all unpaid balances not paid by the due date on your monthly statement.

I authorize WEST BROWARD PEDIATRICS and it's agents Dr. Michael Morrison, Dr. Alicia Salland, Dr. Paole Pare, Brenda Austin, APRN, Amber Badal, APRN, and Kelly Stars, APRN to render any emergency care for my children if I cannot be located at the time of emergency.

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.

Parent/Legal Guardian Signature (Or Signature of Patient 18 Years or Older)

Date

Your information will be encrypted.