Patient Information Sheet

Please correct the errors described below.

When an email address is provided, you will be Web enabled to our patient portal:

Parents names:

Preferred Pharmacy

Electronic Prescriptions: Our electronic medical record program accesses your prescription/medication history in order for us to safely prescribe your medication. By signing this form, you authorize us to do so.

Immunizations: Our electronic medical record program allows for your immunization data to be sent directly to the I-CARE State of Illinois Registry. I-CARE allows your providers to obtain your immunization history to ensure your safety. By signing this form, you authorize us to submit this data.

Insured Subscriber / Responsible Party Information

Consent to Medical Treatment

By signing below, I consent to and authorize the physicians, nurses and other healthcare providers at Bloomington Pediatrics & Allergy to perform appropriate healthcare examinations, treatment, diagnostic testing or medication administration as deemed medically necessary by their professional judgment. I know that there are some risks with all medical treatments and procedures and I understand that no one can guarantee how well treatments or procedures will work. In addition to the legal guardians of the patient, the following persons are authorized to consent to recommended medical care for my child:

Add new row for another legal guardian

Responsibility for Payment for Services Rendered

By signing below, I authorize Bloomington Pediatrics & Allergy to submit claims for services rendered to the insurance company/companies listed by me. I authorize the release of protected health information to said insurance companies for the processing of claims. I understand that I am responsible for payment of services rendered and agree to pay any fees for services not covered by insurance, including, but not limited to co-insurance and deductible amounts. I agree to pay at the time of service any co-payment required by my insurance. I also understand I will be held responsible for the payment of any collection fees should my account be sent into collection proceedings.

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.

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