Please provide an emergency contact. We may need to we need to urgently contact you with information about your child. If we are unable to reach a parent or guardian, who should we contact?
Small Town Pediatrics needs to know some information about the "guarantor" or "subscriber" to the health insurance policy providing coverage for the child or children being registered.
The "guarantor" is the adult who provides the health insurance and/or pays for the child's medical care costs. This may be the same as the primary or "custodial" parent or another person...
If one or more children do not have health insurance, enter the name of the person responsible for paying for the office visit bills as the "guarantor"
Information From Patient Insurance Card
Insurance Info Pro Tip: Send us a photo of the front and back of the "primary" insurance cards for your child or children!
We only need one photo of the back of the card for each plan. If the guarantor or another an adult has the same information on the back of their card, the child's fronts can be photgraphed or scanned with the parent's card back.
First Child Information
Second Child Information
Third Child Information
Fourth Child Information
Fifth Child Information
The "guarantor" is the adult who is responsible for providing the insurance and or paying for the child's healthcare. This is the same as the "subscriber" to the health insurance.
Second Insurance Plan
By clicking "ENROLL" below, you are requesting that Small Town Pediatrics create a family account for you and your child or children. To complete this process we may need to contact you by phone, text or email for clarification or additional information.
If you have additional children to enroll, primary insurance plans or "secondary insurance" we will follow-up with you to collect that additional information. In some cases we may wait to follow-up until a child has an appointment with us.
There is no charge to you nor your insurance for setting up these accounts. The only purpose is to make it possible to schedule appointments, communicate with you and bill for future medical services.