New Patient Forms

Please correct the errors described below.

Acknowledgement of Receipt of Notice of Privacy Practices For Valley Pediatrics, P.C.

By signing this document, I acknowledge that I have received a copy of VALLEY PEDIATRICS' Notice of Privacy Practices.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

For VALLEY PEDIATRICS' Use Only

-OR-

Patient Data

Responsible Party

Insurance

Primary

Secondary

Other

-OR- Patient - Hospital - Physician Directory - Family Member - Friend - Newspaper - Yellow Pages

  • I authorize any holder of medical or other information about me to release this information to my insurance company; its intermediaries or carriers, to my attorney, or another physician office.
  • I hereby authorize direct payment of medical and/or surgical benefits, to include major medical benefits to which I am entitled, Medicare, Private Insurance, and any other health plan to Abington Memorial Hospital, Holy Redeemer and/or Doylestown Hospital.
  • I also permit a copy of this authorization to be used in place of its original. This assignment will remain in effect until revoked by me in writing.
  • I understand that I am financially responsible for ALL services provided to my child(ren), including COPAYMENTS and BALANCES NOT-COVERED or REMAINING AFTER INSURANCE BENEFITS.
  • I authorize Valley Pediatrics, P.C. and Valley Pediatrics at Warrington to give my child(ren) reasonable and proper medical care by today's standards.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

give Valley Pediatrics, P.C. permission to call this

with any test results or reports and leave a message on a voicemail or answering machine if no one answers.

I will notify Valley Pediatrics, P.C. if there is a change in the above phone number.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

I give Valley Pediatrics, P.C. permission to release my medical information to my parents.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

School/ Camp/ Sport Record

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Family History Information Sheet

Siblings

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Patient Health History - Please include immediate family members

Select one - If YES, please explain

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