Pediatric Face sheet

Jersey Medical Weight Loss Center / Aparna Medical Associates

2186, Route 27, Suite 1B North Brunswick NJ 08902
Pediatric Face Sheet

TEENS Weight Loss Program
Today's Date

DayMonthYear
Date
Name

First NameLast Name
Gender

MaleFemaleN/A
Birth Date

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Parent/ Guardian:

First NameLast 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

CityState / Province

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

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

YesNo
Name of Insurance Plan
Responsible Person

ParentOther
Subscriber Name

First NameLast Name
Subscriber ID Number:
Date of Birth

MonthDayYear
Date
Do you have secondary Insurance?

YesNo
Name of Insurance Plan:
Subscriber Name:

First NameLast Name
Relationship to Patient
Subscriber ID
Date Of Birth

MonthDayYear
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

CityState / Province

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

YesNo
Can we text or send email appointment remainder?

YesNo
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 pocketI do not wish to share my child's health-related information with my insurance companyI 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

MonthDayYear
Date
Name of Parent/ Guardian

First NameLast Name
Signature of Parent/Guardian *

Clear
Should be Empty:

Jersey Medical Weight Loss Center / Aparna Medical Associates

Pediatric Face Sheet

Payment/ Insurance Information

General Information

Patient Enrollment Form

Self-pay