Pediatric Care of Morris - Child/Dependent Registration Form

Patient’s Primary Address
Address
City, State, Zip:
County
Country
Preferred Method of Contact:

HomeCellWorkAlt PhoneLetterEmail
Home Phone
Cell Phone
Work Phone
Alt Phone
Email
Email

No EmailPatient refused

Pharmacy Name, Address & Phone #:

Insurance Information

Please provide a copy of the card
PRIMARY CARRIER
Phone Number
Please enter a valid phone number.
Address
Child’s ID
Subscriber’s Name
Group/Plan#
Effective Date

MonthDayYear
Date
Subscriber’s DOB

MonthDayYear
Date
Sex

MFOther
Patient Relationship to Insured
PCP listed on Card
Guarantor Information (Guarantor is the person financially responsible for this patient’s bill.)
Guarantor
Patient’s Relationship to Guarantor
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Sex

MFOther
Phone Number
Please enter a valid phone number.
Email
example@example.com
Employer
Employer Address

Emergency Contact Information

(Someone living outside the primary household)
Name

First NameLast Name
Patient’s Relationship to Contact
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Assignment of Benefits/Authorization/Notice of Collection Action
I understand I am responsible for knowing the benefits my insurance plan provides. In doing so, it is also my responsibility to verify proof of insurance by ensuring
that the office staff has the most current/valid insurance card on file. I further understand that all co‐payments are due at time of service and I am also responsible to
pay other amounts due; these amounts may include annual deductibles, charges denied by my insurance company as not covered or not medically necessary, and/or
any fees incurred should my account require collection action. (E.G. late fees, collection agency, court or attorney costs). Also, please be advised our office may
contact you via an automated system regarding appointments and/or account status. I agree this authorization shall remain valid unless/until I rescind in writing.
(Please see the Primary Care Partners Payment Policy and Notice of Privacy Practices for more information)
Signature

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Print Name
Signed on

MonthDayYear
Date
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