New Patient Information

APPOINTMENTS ARE NOT SCHEDULED UNTIL INSURANCE IS VERIFIED

The practice is not accepting any new Medicaid or Medicaid HMO patients.

FIRST TIME FAMILY

YES NO

TODAY'S DATE

RETURNING FAMILY

YES NO

FAMILY LAST NAME

FATHER

FATHER DATE OF BIRTH:

MOTHER

MOTHER DATE OF BIRTH:

ADDRESS

CITY:

STATE:

ZIP CODE:

Primary Phone #

Secondary Phone #

E-MAIL ADDRESS:

PENDING ADOPTION?

YES NO

IF YES: CASEWORKER NAME:

CASEWORKER PHONE#

NAME OF CHILD(REN)

Add new row

IF OTHER, SPECIFY:

REASON FOR CHANGE:

FORMER PROVIDER:

NAME

ADDRESS

PRIMARY INSURANCE:

IF NEWBORN, PLEASE INDICATE

MOTHER FATHER

PATIENT NAME

INS. CO. NAME:

POLICY EFFECTIVE DATE:

POLICY OWNER'S NAME:

RELATIONSHIP TO PATIENT:

POLICY HOLDER'S DOB:

SSN

EMPLOYER NAME:

GROUP NO:

POLICY/ID NO:

COPAY AMT:

or % OF VISIT

INS. CO. PHONE #

SECONDARY INSURANCE, IF APPLICABLE.

IF NEWBORN, PLEASE INDICATE

MOTHER FATHER

PATIENT NAME

INS. CO. NAME:

POLICY EFFECTIVE DATE:

POLICY OWNER'S NAME:

RELATIONSHIP TO PATIENT:

POLICY HOLDER'S DOB:

SSN

EMPLOYER NAME:

GROUP NO:

POLICY/ID NO:

COPAY AMT:

or % OF VISIT

INS. CO. PHONE #

I certify that my child(ren) has/have the commercial insurance coverage(s) referenced above. I understand that my child(ren) is/are being accepted as new patients with ESD Pediatric Group contingent upon maintaining primary and secondary (if applicable) commercial health insurance which is currently accepted by the practice for a minimum of twelve (12) months. Should commercial insurance lapse or the child(ren) become(s) ineligible for coverage during the twelve (12) month period, the patient(s) will receive a written notification of dismissal.

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/Guardian Signature

Date

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