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For your convienence, print and complete the registration form to expedite new patient registration at your first visit.\r\n
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Referred By: ________________________ \r\n
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PATIENT REGISTRATION / INFORMATION \r\n
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Patient Name: ______________________________Date of Birth____________
\r\n Address:___________________________________
\r\n City_____________________State______________Zip_____________
\r\n Telephone#_______________ Cell# _______________
\r\n Social Security# (if known)_______________Email address_________________ \r\n
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Allergies No Yes (please list) ________________________________ \r\n
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Emergency Contact_________________Telephone__________________Relation___________ \r\n
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PARENT INFORMATION \r\n
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Mother’s Name________________________ Father’s Name ___________________________
\r\n Address______________________________ Address_________________________________
\r\n Telephone # __________________Telephone# ________
\r\n Cell/Beeper#__________________________ Cell/Beeper#_____________________________ Employer_____________________________Employer________________________________
\r\n Address:________________________ _____Address_________________________________
\r\n Social Security #____________________Social Security # _____________________
\r\n DOB: ______________________________ DOB:____________________________________
\r\n Email_______________________________ Email____________________________________ \r\n
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INSURANCE
\r\n PRIMARY SECONDARY N/A YES
\r\n Insurance Company____________________ Insurance Company________________
\r\n Policy Holder_________________________ Policy Holder_____________________
\r\n DOB_____________ ID#_______________ DOB___________ ID#______________
\r\n GRP#_______________________________ GRP#____________________________
\r\n Employer_____________________________ Employer________________________ \r\n
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INFORMATION AND ASSIGNMENT OF BENEFITS
\r\n 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 anytime in writing.
\r\n I hereby authorize BEACH 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 BEACH PEDIATRICS.
\r\n I certify that the above information is true and correct and that I have received and understand the HIPAA privacy form. \r\n
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Date_____________________Signature____________________________________________\r\n
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