New Patient Intake Form

COMMERICAL INSURANCE

Our office is in network with most commercial insurance payers offered in the area. Please familiarize yourself with the coverage of your plan and its restrictions. Per your insurance policy, you are ultimately responsible for co pays and deductibles as well as services that are not a covered benefit.

The first appointment scheduled will be a new patient comprehensive examination. It is designed to include a thorough review of their past medical history.

How did you learn about our office?

***NOTE: Please watch for a return email from our office. We will contact you via email for additional information and/or when your child has been pre-registered and ready for you to call and schedule a new patient visit.***

Child's Name

First name

Last name

Date of birth

Gender at Birth

Male

Female

Street Address

City

Zip Code

Parent or Guardian Information

First name

Last name

Primary Phone Number

Relationship to child

Email address

Medical History

Has the child been treated by a doctor in the last 12 months?

Yes No

If yes, please describe the reason for the visit

What medications is the child taking (if any) and for what conditions? Include the dosage and amounts. If none, please write NONE.

Do you currently have any medical concerns which the doctor needs to know right away?

Important: Indiana Law requirements -- We must have a current vaccine record AND record of lead screening to be on file.. You must contact the last physician to obtain this information if you do not have it.

Yes- I have vaccine and lead record -Take a photo and UPLOAD vaccine and lead record below No - I do not have any records -If you are coming from out-of-state, please request vaccine record and lead record as it legally can take 30 days to process. May fax to 317-293-3991.

Vaccine Record Photo If you are not able to upload here, please fax to 317-293-3991 or drop off to our office.

Add file

Please upload a file

Vaccine Record - If more than 1 page

Add file

Please upload a file

Lead Test/Medical Records If you are not able to upload here, please fax to 317-293-3991 or drop off to our office.

Add file

Please upload a file

Lead Test/Medical Records

Add file

Please upload a file

Medical coverage under Medicaid

Medicaid ID Number:

If your child has Medicaid, they must have (MHS) MANAGED HEALTH SERVICE and Dr. Hayford must be already assigned by Medicaid. We are NOT able to accept any new patients other than those with MHS and assigned to Dr. Hayford at this time.

Insurance Information #1 (NOT MEDICIAD) Take a PHOTO and Upload

Insurance card copy - FRONT

Add file

Please upload a file

Insurance card copy - BACK

Add file

Please upload a file

Name of Insurance Company

Member ID number

Please upload a copy of insurance card above OR provide mailing address listed on the back of card.

Subscriber Name

Subscriber DOB:

Subscriber Address - including City, State, Zip:

Insurance Information #2 (NOT MEDICAID) Take a PHOTO and Upload

Insurance card copy - FRONT

Add file

Please upload a file

Insurance card copy - BACK

Add file

Please upload a file

Name of Insurance Company

Member ID Number:

Please upload a copy of insurance card above OR provide mailing address listed on the back of card.

Subscriber Name:

Subscriber DOB:

Subscriber Address- including City, State, Zip:

You may always reach us by using our secure link at www.indypeds.com using the SECURE CONTACT US

A member of our staff will be in contact with you tomorrow or the next business day. Please watch your email. Thank you.

Your information will be encrypted.

New Patient Intake Form

COMMERICAL INSURANCE

The first appointment scheduled will be a new patient comprehensive examination. It is designed to include a thorough review of their past medical history.

Child's Name

Parent or Guardian Information

Medical History

Medical coverage under Medicaid

Insurance Information #1 (NOT MEDICIAD) Take a PHOTO and Upload

Insurance Information #2 (NOT MEDICAID) Take a PHOTO and Upload

COMMERICAL INSURANCE

Indianapolis Independent Pediatricians