Patient Information

Please correct the errors described below.

PATIENT INFORMATION: THIS SECTION REFERS TO THE PATIENT ONLY

Name

Date of Birth

Phone

Current Address

City

State

Zip

Parent Email Address

Sibling Names

Gender

Male Female

Race

American Indian Alaska Native Asian Black/African American Native Hawaiian White More than one race Unreported/Refused to Report

Ethnicity

Hispanic/Latino Non Hispanic Unreported/Refused to Report Race and Identity

PARENT AND GUARDIAN INFORMATION

Father’s Name

Address

City

State

Zip

Phone

SSN

Date of Birth

Mother’s Name

Address

City

State

Zip

Phone

SSN

Date of Birth

This section refers to the PERSON WHOSE NAME IS LISTED ON THE INSURANCE CARD: SUBSCRIBER INFORMATION

Insurance Company Name

Subscribers Name

Date of Birth

SSN

Phone

Current Address

City

State

Zip

Current Employer

Phone

AUTHORIZATION TO PAY BENEFITS TO THE PHYSICIAN

I hereby authorize the office of NAVARRE PEDIATRICS PL to release any medical information required during the course of examination and treatment and permit payment directly to them any benefits due for their services rendered. I recognize and accept responsibility for services rendered regardless of insurance coverage. This include, but is not limited to, coinsurance, co-payment, deductible and non-covered services.

Signature

Date

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