Registration Forms

ADVANCED PEDIATRIC CARE, LTD.

Please correct the errors described below.

MARIA CHRISTINE BAYANG, M.D.

MUHAMMAD N. LONGI, M.D.

MOAZZAM SAEED, M.D.

300 Read Street, Suite D - Lockport, IL 60441

Telephone: (815) 838-7337 Fax: (815) 838-5007

215 Remington Blvd, Bolingbrook, IL 60440

PATIENT INFORMATION

PRIMARY INSURANCE

Person Responsible for Account

ADDITIONAL INSURANCE

ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent(s), have insurance coverage with

and assign directly to

all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

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.

Initial History Questionnaire

Household

Please list all those living in the child's home.

Add new row

Birth History

During pregnancy, did mother :

General

Family History

Have any family members had the following:

Past History

Does your child have, or has he/she ever had:

Your message will be encrypted.