Patient Profile Form

Pediatric & Adolescent Associates

Please correct the errors described below.

Patient Information

Text Message or Email for Appointment Reminders?

Siblings Information

Primary Guardian/Financially Responsible

Other Parent/Guardian Contact Information

Primary Insurance Information

Insurance Holder

Important Contacts:

  • Insurance Coverage is a contract between you and your insurance company. It is your responsibility to know what your plan does and does not cover.
  • We will file insurance claims for you, but you are responsible for amounts not paid by insurance within 90 days.
  • I understand that I am responsible for any balance not covered by insurance. I also understand that all co-payments, deductibles and co-insurances are due at the time of service.
  • As parent or legal guardian, I authorize payment of medical benefits to be made directly to Pediatric & Adolescent Associates, PSC for services performed. I further agree to be fully responsible for all lawful debts incurred for services provided.
  • I consent to be contacted by regular mail, by email or by telephone (including a cell phone number) regarding any matter related to our account with Pediatric & Adolescent Associates, PSC.

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