Newborn Registration Form

Newborn 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
Parent/Guardian #1*

First NameLast Name
Social Security Number*
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
Date of Birth

MonthDayYear
Date
Social Security Number
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.
How did you hear about Saugatuck Pediatrics?
Party responsible for payment of medical services (please choose ONE)*

Parent/Guardian #1Parent/Guardian #2Guardian
Insurance Information (you must provide us with a copy of your current insurance card)
Insurance Company*
ID Number*
Insurance provided through:*
Name of Insured*

First NameLast Name
Note: You need to select one of our physicians as your primary care physician and notify your insurance of selection.
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
If mother and father are not living together, or if child does not live with parents, what is the child’s custody status?
Baby’s Insurance Coverage

Thank you for entrusting our practice with the medical care for your child. We want to offer a little insight on the first month of insurance/Medicaid coverage in our office.

·      Mom’s insurance covers your baby in the event of an illness or an emergency, even before they are added on to the policy individually. That is not to say that you do not have to enroll your baby at all. If your baby is NEVER added to the policy or enrolled in coverage, the claim payment is taken back from the practice and the balance becomes your responsibility to pay.

·      Mom’s insurance coverage DOES NOT cover your baby for Wellness exams. The baby MUST BE added to the policy individually or receive their own ID# before services are paid to the clinic.

·      Mom’s insurance DOES NOT cover your baby for vaccines. The baby MUST BE added to the policy individually or receive their own ID# before services are paid to the practice.

We make the choice to continue offering medical care for your newborn in the first 30 days of life, even when we have significant payment delays for the services. We need YOUR HELP getting your newborn covered on their own under your family policy or with their own Connecticut Medicaid ID# as soon as possible.

If you do not add your newborn before the first 30 days of life, the balance for ALL SERVICES rendered in the first 30 days of life may be your financial responsibility.

Please make sure to enroll your infant as soon as possible to your family’s private insurance plan or enroll them in CT Medicaid to avoid payment issues for both you and the practice.

Thank you!
Saugatuck Pediatrics
What insurance will your infant be covered under? (Husky or Private- please name insurance company). You can find the insurances we accept on our website at www.saugatuckpeds.com.*
Signature acknowledging Baby's Insurance Coverage information*

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Date*

MonthDayYear
Date
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 HIPAA safe and securely encrypted format through our credit card processor.

Please enter $0*

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

Preferred pharmacy*
Is there a family history of any of the following?*

NoneAsthmaParent or sibling needing glasses prior to age 10Heart disease such as atherosclerosis or a heart attack prior to age 50Heart arrhythmiaAnemiaBleeding disorderClotting disorderLiver diseaseKidney diseaseEndocrine disease (thyroid, adrenal, pancreatic disorders, etc.)Autoimmune disease (Crohns disease, Ulcerative Colitis, Graves disease, Hashimoto's disease, Vitiligo, Celiac etc.)DiabetesEpilepsy (seizures)Drug abuseAlcohol abuseMental illnessLearning disabilityImmune deficiencyCancerGenetic disorderFrequent ear infectionsDeafnessOther
If you have answered YES to any of the above, please elaborate (who carries the diagnosis, etc.)
Please verify that you are human
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