New Patient Demographics Form

Please correct the errors described below.

Patient Information

Primary Guarantor Information & Insurance

Parent / Guardian Information

Parent / Guardian #1: (if different than Guarantor Information)

Parent / Guardian #2: (if different than Guarantor Information)

Emergency Contact

Please list someone other than Parent / Guardian

Assignment & Release

Please review and sign authorizations below to expedite claim processing. If you feel that a claim has been denied in error, it is your responsibility to contact the insurance company. Questions regarding your account may be directed to our Practice Manager, Jake Masterman, at 813-563-6070.

I hereby authorize payment of medical benefits directly to Sandhill Pediatrics PA. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents.

I authorize the above doctor and/or provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.