Pediatric Health Care Associates Patient Registration Form

Please correct the errors described below.


Family Member Information Please List Parents and Only The Children That Come To This Practice




Add another child

Primary Medical Insurance

Name of Policyholder

Address (* If different than above)

Insurance Address

*Pediatric Health Care will file insurance claims for you. However, you are responsible for all fees, regardless of insurance coverage.

Assignment of Benefits

I Authorize Payments of Medical Benefits To The Above Named Provider For Medical Services Rendered. I Authorize The Release of Any Medical Information Necessary To Process Insurance Claims.

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