Patient Profile Form

Patient Information

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.

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.