Registration Forms

Parent/Guardian Information: (MOTHER'S INFORMATION - OR - GUARDIAN)

Parent/Guardian Information: (FATHER'S INFORMATION - OR - GUARDIAN)

Patient Information

**IF YOU HAVE MORE THAN ONE CHILD PLEASE SELECT "ADD PATIENT" **

Insurance Information

Primary Insurance Company

Secondary Insurance Company

Tertiary Insurance Company

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.

OFFICE USE ONLY

Other children who come to this practice who are also included in this consent:

In the event that I, or another parent or legal guardian, am unable to be present for my child(ren’ s) visit, the. following people are authorized to bring the above named child(ren) to Pediatric Associates for treatment. This permission shall remain in force until I give written notification to Pediatric Associates.

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.

Acknowledgment of Privacy Notice

By signing below, I hereby acknowledge the receipt of a copy of the Pediatric Associates Notice of Privacy Practices. (HIPPA)

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.

Please list the COMPLETE names and dates of birth of all children in your family, who come to this practice:

OFFICE POLICY FOR PATIENTS WITH INSURANCE COVERAGE

It is customary to pay for services when rendered unless other arrangements have been made in advance. In order to accommodate the needs and requests of our patients, we have enrolled in many insurance companies.

While we are pleased to be able to provide this service to you, it is not possible for us to keep track of all the individual policies, changes and updates of the plans. Each has different requirements regarding how often services may be rendered, and even more importantly, where those services may be performed. It is mandatory that you, as the patient, know your policy. Within the same insurance company the plans differ depending upon what type of contract your employer has negotiated.

Providing quality medical care for our patients is our primary concern. We are more than willing to provide that care within your insurance contract guidelines if you let us know at each time of service, exactly what are those guidelines.

Unfortunately, if you do not inform us of any special requirements in your contract and we subsequently order services(such as testing, lab work, hearing and vision screenings) that are not covered, our office or the selected medical facility will have no choice but to bill you directly for those charges. Payment for those charges is then your responsibility.

If your insurance changes or is not active for services to be billed and we are not clearly notified and documented, you will be responsible for all fees that have been incurred. If your insurance company violates its contract with our office, you will be responsible for all financial balances.

In the event we don’t participate with your insurance company and we are able to bill them partial payment, you will be responsible for any balance left unpaid by your insurance.

Any costs incurred in the collection of monies owed will be the responsibility of the parent.

I have read and understand the office policy and agree to accept responsibility as requested. I authorize direct payment to Pediatric Associates.

I have received and/or read the Notice of Privacy Practices provided to me by Pediatric Associates. J agree to allow Pediatric Associates to share information with family pertaining to my care. If I disagree or wish to exclude anyone I will list below:

Release of Information to Insurance Company .

NOTE: Your health information will be kept confidential. Any information that we collect about you on this form will be kept confidential in our office. If a claim is submitted to your insurance carrier, your health information on this form may be shared with them. Your health information which any insurance carrier sees will be kept confidential by them. I also grant Pediatric Associates permission to view my child’s prescription history from external sources.

This consent will stay in effect until we receive written notification from you.

I AGREE TO AND UNDERSTAND ALL CONTENTS ON THIS FORM. THE SIGNATURE BELOW IS FOR ALLITEMS WITHIN.

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.