NEW PATIENT APPOINTMENT FORM

PATIENT INFORMATION

First Name of Patient

Last Name of Patient

Sex of Patient

M F

Patient Date of Birth

Phone Number

Address

How did you hear about us ?

PCP Change Reference Number

What is Your Visit Concern

INSURANCE

Type of Insurance

Commercial Medicaid Self Pay Unsure

Insurance Plan Name

Subscriber ID

Also known as member ID

Relationship of Patient to Insured

Medicaid holders, please type in 'Seff'

Upload Photo of Front of Insurance Card

Add file

Please upload a file

Upload Photo of Back of Insurance Card

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Please upload a file

VACCINATIONS

Are you hesitant or unsure about vaccinating?

Yes No

Are you seeking an alternate or delayed vaccination schedule?

Yes No

Is the patient from out of state (new to Texas)

Yes No

If you wish to vaccinate your child/ward, please complete the Texas Immunization Registry Consent Form.

Upload Texas Immunization Registry Consent Form You can also email the completed form to newpatients@npakids.com with the patient name + vaccination consent form as the email heaader

Add file

Please upload a file

NEWBORNS

Is the patient a newborn If the patient is 3 months or younger, please select yes

Yes No

Upload New Born Discharge Papers Here

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Please upload a file

NEWBORN ADDITION TO INSURANCE DECLARATION

Please ensure that you enroll newborn infants with your insurance carrier (usually the mother’s) before scheduling your appointment. Provide the following details from the insurance enrollment call.

Date of Call

Time of Call

Insurance Representative’s Name

Reference Number

Estimated timeframe provided by the insurance representative for updating the newborn’s information in the system.

Declaration: I confirm that I/my family has active insurance coverage. I confirm that I have enrolled my newborn infant with my insurance carrier for provision of coverage ahead of my first appointment. I agree to take financial responsibility in case of non-coverage/non-enrollment.

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