Family Registration Form

Family Registration Form
Saugatuck Pediatrics LLC

191 Post Road West, Suite 201

Westport, CT 06880

www.saugatuckpeds.com

Phone (203) 793-4747

Fax (877) 809-0848
Please make sure to also complete and submit a record release to your previous pediatric office, and allow a week for us to create your family's Saugatuck electronic record following submission of the family registration form.
Parent/Guardian #1*

First NameLast Name
Occupation
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email*
example@example.com
Parent/Guardian #2

First NameLast Name
Occupation
Address (if different from Parent/Guardian #1)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email
example@example.com
Child #1

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Child #2

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Child #3

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Child #4

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Child #5

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Names, relationship, and cell phone numbers of individuals (other than parents) who might be bringing children in for visits.

* Note: The person bringing in the child is responsible for payment.
Name

First NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.
By checking this box you agree to receive text messages from Saugatuck Pediatrics, you can reply stop to opt-out anytime.

Type option 1
Party responsible for payment of medical services (please choose ONE)*

Parent/Guardian #1Parent/Guardian #2Guardian
I authorize Saugatuck Pediatrics LLC to charge my card on the amount indicated in this form for outstanding charges, and this authorization shall remain in effect until I request for the cancellation or termination.

I likewise certify that I am the authorized user of the Credit Card that shall be submitted through this form. As long as the transactions correspond to the terms and conditions indicated in this authorization, I shall not raise disputes against the company.

All cards are stored in a securely encrypted format through our credit card processor.
Insurance: Saugatuck Pediatrics participates with Aetna, Anthem Blue Cross Blue Shield, Cigna, Multiplan, Connecticare and Husky. We are on some specific Empire BCBS plans, please check with your insurance representative to see if we are listed.We do not accept any ACA (exchange) plans other than Connecticare. We will accept United/Oxford as of January 1st, 2024. Many patients do come to us out of network. Please note that patients who are out of network are expected to pay for the full cost of the visit at the time of service.
Insurance Company*
Note: You need to select one of our physicians as your primary care physician and notify your insurance of selection.
ID Number- if Husky, or you have different policies for your children, please enter the information of your oldest child*
Insurance provided through:*
Name of Insured*

First NameLast Name
Date of Birth of Insured*

MonthDayYear
Date
Authorization of Treatment and Assignment of Benefits:

I authorize Saugatuck Pediatrics LLC to treat my child/children. I further authorize the release of medical information necessary for the completion of insurance forms, school & camp forms. I authorize payment directly to Saugatuck Pediatrics LLC, for any and all medical or surgical benefits otherwise payable to me under the terms of my insurance. I also affirm that I will reimburse Saugatuck Pediatrics for any payments my insurance company may have sent to me in error. I understand that I am financially responsible for all co-payments and any charges not covered under my insurance benefits. I also understand that I am responsible for advising Saugatuck Pediatrics LLC of any and all changes to my insurance. Co-payments are due on date of service. Failure to do so will result in an additional billing charge of $25.00. Our office requires 24 hours notice of appointment cancellation. Failure to provide this notice will incur a cancellation fee.

Saugatuck Pediatrics LLC requires a credit card on file. If there is an outstanding balance we will contact you to see if you would like it placed on your credit card or if you would like to pay by another method.
Signature

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Relationship*
Date*

MonthDayYear
Date

This field is only for card storage (in a secure, encrypted format). The payment will be voided once received.*

USDMedical Fees

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

If mother and father are not living together, or if child does not live with parents, what is the child’s custody status?
Preferred Pharmacy*
Family Medical History (pick as many options as apply)*

NoneAsthmaParent or sibling needing glasses prior to age 10Heart disease such as atherosclerosis or a heart attack prior to age 50Heart arrhythmiaAnemiaBleeding disorderLiver diseaseKidney diseaseEndocrine disease (thyroid, adrenal, pancreatic disorders, etc.)Autoimmune disease (Crohn's disease, Ulcerative Colitis, Vitiligo, Graves disease, Hashimoto's disease, etc.)DiabetesEpilepsy (seizures)Drug abuseAlcohol abuseMental illnessLearning disabilityImmune deficiencyCancerGenetic disorderFrequent ear infectionsDeafnessother
If you have answered YES to any of the above, please provide details (specific family member, specific type of issue...)
We participate in Connecticut’s Clinical Document Exchange:

What is Clinical Document Exchange?

Clinical Document Exchange allows different healthcare organizations to exchange patient records. Your participation allows other providers you see to obtain your patient records for treatment purposes.

For example, you child is seen by a specialist or in the Emergency Room at another hospital. That provider can quickly access your child’s records to find out what medications your child is taking, or that they have a medication allergy.

How much of my data is being shared?

Your most up-to-date Summary of Care record is made available and contains information including:

·      Demographic data (name, date of birth, address)
·      Clinical data
o   Diagnoses
o   Allergies
o   Medications
o   History of Procedures
o   Diagnostic and Laboratory Test Results
o   History of Immunizations
·      Insurance Policies

Who has access to my data?
Only providers at healthcare organizations that participate in Clinical Document Exchange through the Interoperability Framework Care Quality are able to retrieve your records. They may retrieve your records for treatment purposes only.

How is my data secured?
In accordance with industry standards many layers of security, including encryption, protect patient data when it is transmitted to a different healthcare organization.
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