New Patient Form

Please Fill In Every Space. A Complete Record Is Needed For Each Child. Thanks.

Please correct the errors described below.

List All Brothers and Sisters of this Patient (Including Step - and half - Brothers and Sisters

Add Sibling

Insurance Information

I HAVE BEEN GIVE A COPY OF THE OFFICE'S FINANCIAL POLICY AND I UNDERSTAND THAT OFFICE SERVICES ARE PAYABLE AT THE TIME SERVICES ARE RENDERED.

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.

ASSIGNMENT OF BENEFITS

I HEREBY ASSIGN MY INSURANCE BENEFITS UNDER THE ABOVE PLANS FOR TREATMENT RENDERED TO THE ABOVE NAMED CHILD BY THE PHYSICIANS OF THE NORTH OAKS PEDIATRIC CLINIC, LLP, HAMMOND, LA. THIS ASSIGNMENT IS EFFECTIVE UNTIL REVOKED BY ME IN WRITING, AND A PHOTOCOPY SHALL BE CONSIDERED AS VALID AS THE ORIGINAL. I AUTHORIZE THE CLINIC TO RELEASE ANY INFORMATION NECESSARY TO PROCESS INSURANCE CLAIMS FOR ME.

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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