New Patient Form

Patient Information

First Name

Middle Initial

Last Name

Address

Apt

Country

State

Zip

City

Date of Birth

Gender

Male Female

Primary Guardian Information

First Name

Middle Initial

Last Name

Address

Apt

Country

Zip

State

City

Date of Birth

Gender

Male Female

Phone

cell

Work

Employer

Secondary Guardian Information

First Name

Middle Initial

Last Name

Address

Apt

Country

Zip

State

City

Date of Birth

Gender

Male Female

Phone

Cell

Work

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

Emergency 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

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