Patient Registration/Information - English Form

For your convenience, please complete the registration form to expedite new patient registration.

Patient Registration/Information

Parent/Guardian Information

Insurance Information

Primary

Secondary (If Applicable)

Information and Assignment of Benefits

I authorize the release of any medical information necessary to process this claim. I permit a copy of this authorization to be used in place of the original. The authorization may be revoked by either me or my insurance company at any time in writing.

I hereby authorize PARTNERS IN HEALTH PEDIATRICS to apply for benefits on my behalf for covered services rendered by or ordered by. I request that payment from my insurance company be made directly to my physician with PARTNERS IN HEALTH PEDIATRICS.

Authorization to Mail/Call/Email

I certify that I understand the privacy risks of mail, phone call and email. I hereby authorize PARTNERS IN HEALTH PEDIATRICS representative or my physician to call, email or mail me with communication regarding my healthcare including but not limited to appointment reminders, referral arrangements and laboratory results. I understand that I have the right to rescind this authorization at any time by notifying PARTNERS IN HEALTH PEDIATRICS to that effect in writing

General Consent for Treatment

do hereby, consent to any medical care and treatment by Sonober Umair, MD and/or affiliated/ covering provider for the benefit of my child while said child is under the care of PARTNERS IN HEALTH PEDIATRICS.

I certify that the above information is true and correct and that I have received and understand the HIPAA privacy form.

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.