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