Patient Information First Name Middle Initial Last Name Address Apt Country Zip State City Date of Birth Gender MaleFemale Primary Guardian Information First Name Middle Initial Last Name Address Apt Country Zip State City Date of Birth Gender MaleFemale Email Phone cell Work Marital Status MarriedSingleDivorcedWidowedSeparated Employer Secondary Guardian Information First Name Middle Initial Last Name Address Apt Country Zip State City Date of Birth Gender MaleFemale Email Phone Cell Work Marital Status MarriedSingleDivorcedWidowedSeparated Employer Primary Insurance Insurance Company Name of Insured Insured Member’s SSN Policy Number Insured Member’s Employer Insured Member’s Relation to Patient Insured Member’s Date of Birth Insured Member’s Group Number Secondary Insurance Insurance Company Insured Member’s SSN Insured Member’s Employer Policy Number Insured Member’s Relation to Patient Insured Member’s Date of Birth Insured Member’s Group Number Other Children Name Date of Birth Name Date of Birth Name Date of Birth Name Date of Birth Emergence Contact Information Please list anyone other than the primary & secondary guardian that can bring this child into our office for treatment Name Relationship to Patient Name Relationship to Patient I have read and understood the Notice of Privacy Practice. Patient’s Parent Name Today’s Date Signature Financial Obligation Please initial by each statement and sign and date at the bottom I understand that I am ultimately responsible for all charges incurred on behalf of my minor child or the child who is seeking medical care while in my custody. Any co-pays, deductibles, or charges which are denied coverage from my commercial insurance company are my responsibility and will be paid at the time they are incurred. I hereby authorize the release of any medical information necessary to process insurance claims or any medical information that is required for any health care related utilization review or quality assurance activities. I hereby assign and authorize payment to Lifeguard Pediatrics, PC of all medical/surgical/major medical benefits to which I am entitled under any insurance policy or policies, under any self-insurance program or under any other benefit plan. I understand and acknowledge that this assignment of benefits does not relieve me of my financial responsibility, including, but not limited to, payment of those fees and charges not directly reimbursed to Lifeguard Pediatrics by any insurance policy, self-insurance plan, or other benefit plan. This authorization shall remain in effect until revoked by me in writing. A photocopy of this authorization shall be considered as effective and valid as the original. I understand that I have the right to receive a copy of this authorization. Signer’s Name Today’s Date Signer’s Relation to Patient Signature
