Pediatrics Face sheet

Jersey Medical Weight Loss Center / Aparna Medical Associates

1527 State Route 27, Suite 2100, Somerset NJ 08873
Pediatrics Face Sheet

TEENS Weight Loss Program
Today's Date

Day Month Year
Date
Name

First Name Last Name
Gender

Male Female N/A
Birth Date

Month Day Year
Date
Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Name of Parent/ Guardian:

First Name Last Name
Relationship to the Patient:
Telephone Number:
Please enter a valid phone number.
Email Address
example@example.com
Home Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Payment/ Insurance Information
Do you have medical insurance?

Yes No
If no medical insurance, do you agree to be self-pay?

Yes No
Name of Insurance Plan
Responsible Person

Parent Other
Subscriber Name

First Name Last Name
Subscriber ID Number:
Date of Birth

Month Day Year
Date
Do you have secondary Insurance?

Yes No
Name of Insurance Plan:
Subscriber Name:

First Name Last Name
Relationship to Patient
Subscriber ID
Date Of Birth

Month Day Year
Date
General Information
Name of the Pediatrician
Telephone Number
Please enter a valid phone number.
Pharmacy Name
Pharmacy Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Pharmacy Telephone
Please enter a valid phone number.
Can we leave a message in your voice mail ?

Yes No
Can we text or send email appointment remainder?

Yes No
Patient Enrollment Form

Patient Acknowledgement Form
We are required by applicable federal & state laws to maintain the privacy of your health information. We are also required for you to review and if requested, give you the Privacy Notice that outlines our privacy practices, our legal duties and your right concerning your health information. We must follow the privacy practices that are described in our Privacy Notice while it is in effect. PLEASE READ OUR PRIVACY NOTICE BEFORE SIGNING. I have reviewed and / or received a copy of the office's Notice of Privacy Practices. I HAVE REVIEWED &/ RECEIVED A COPY OF THE OFFICE'S NOTICE OF PRIVACY PRACTICE *

Clear
Medical Insurance - assignment of benefits/payments
I, the undersigned have medical insurance coverage with Name of Insurance and assign directly to Dr. Aparna Chandrasekaran (Jersey Medical Weight Loss/ Aparna Medical Associates) all medical benefits, if any, otherwise payable to me for services rendered. I authorize release of all the information necessary to secure the payment of benefit. Also, I understand that I am financially responsible for all charges if not paid by the insurance and authorize the use of my signature on all my insurance submission.
Signature *

Clear
Self-pay
I understand that my child's office visit will not be billed to my insurance company and I agree to pay " out of pocket" for all the professional services received at JERSEY MEDICAL WEIGHT LOSS CENTER under the care of Dr. Aparna Chandrasekaran.

I understand the self-pay plan options and agree to pay-out-of pocket I do not wish to share my child's health-related information with my insurance company I give expressed consent to share my child's health-related information with my insurance company.
By signing below, I certify that all the information I provided is true, correct & complete.
Date

Month Day Year
Date
Name of Parent/ Guardian

First Name Last Name
Signature of Parent/Guardian *

Clear
Should be Empty:

Jersey Medical Weight Loss Center / Aparna Medical Associates

Pediatrics Face Sheet

Payment/ Insurance Information

General Information

Patient Enrollment Form

Self-pay