Pediatric Health Care Associates Patient Registration Form

Please correct the errors described below.

Address

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

Father

Mother

Child

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.

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.

Your message will be encrypted.