Patient Information Form

Dr. Hubbell

Dr. Brown

Dr. Worley

Dr. Roesler

Dr. Bartz

Misty Moss, FNP

Cheryl Smith, FNP

PATIENT INFORMATION PACKET

Please fill out all information below.

NAME:

DOB:

ADDRESS:

CITY:

STREET:

ZIP:

HOME PHONE:

SSN:

Parents/Guardian

MOTHER:

DOB:

SSN:

HOME PHONE:

ADDRESS:

CITY:

STREET:

ZIP:

MOTHER EMPLOYER:

MOTHER WORK #:

MOTHER CELL #:

DRIVER'S LICENSE #:

FATHER:

DOB:

SSN:

HOME PHONE:

ADDRESS:

CITY:

STREET:

ZIP:

FATHER EMPLOYER:

FATHER WORK #:

FATHER CELL #:

DRIVER'S LICENSE #:

Emergency Contact - someone not living in the same householdFormatted text

NAME:

RELATIONSHIP:

HOME PHONE:

CELL PHONE:

ADDRESS:

CITY:

STREET:

ZIP:

Information on Insurance Carrier other than parent (grand parent, step parent, etc.)

NAME:

RELATIONSHIP:

DOB:

CELL PHONE:

ADDRESS:

CITY:

STREET:

ZIP:

I am the parent of (Please input Name below) by signing below, I authorized the following people other than the biological mother and/or father, to bring my child to the providers at Beaumont Pediatric Center, PLLC for treatment.

(please print name and relationship to patient)

Add new row

I have received from Beaumont Pediatric Center, PLLC a copy of the company HIPPA Policy, Financial Policy and Office Policy. By signing below, I understand my financial obligations to the practice as well as the Office Policy, HIPPA Policy, and obligations of the practice to protect my child's health information.

Messages may be left regarding my child at the following locations:

Home Phone Ans. Machine

Mother's Cell

Mother's Work

Father's Cell

Father's Work

Other

If other, Please specify:

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.

Parent's Signature

Date:

INSURANCE is a contract between you, your employer and the insurance company. We are not party to that contract. It is very important that you understand the provisions of your policy. It is your responsibility to verify that we are an in-network provider on your specific plan. Insurance plans vary considerably, and we cannot predict or guarantee what part of our services will be covered. It is the responsibility of the parent to provide accurate and timely insurance information. Therefore, we ask you bring your current insurance card and driver's license to each visit. Inaccurate or untimely information given to the staff that results in denial or not coverage by your insurance company will result in a guarantor being responsible for the payment.

Initial

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