Annual Update manual entry

THE CHILDREN'S CLINIC OF CONWAY AND GREENBRIER
Patient name*
Patient Date of Birth*

MonthDayYear
Date
Update Patient Information
Change mailing address?*

No, current mailing address is correctYes, change the mailing address to the address below
Address
City
State
Zip code
Change first listed guardian's information*

No, guardian's information is correctYes, change guardian's information to the following:
First listed guardian name

First NameMiddle InitialLast Name
DOB:

MonthDayYear
Date
Relationship to patient:
SSN:
Home/Cell phone:
Format: (000) 000-0000.
Email address:
example@example.com
Employer:
Change first listed guardian's information*

No, guardian's information is correctYes, change guardian's information to the following:
Second listed guardian name

First NameMiddle InitialLast Name
DOB:

MonthDayYear
Date
Relationship to patient:
SSN:
Home/Cell phone:
Format: (000) 000-0000.
Email address:
example@example.com
Employer:
Change insurance information?*

No, current insurance information is accurateYes, change insurance information to the following
Enter the updated insurance information below or, alternately, click the button below and take a picture of the front and back of your insurance card.
Insurance name
ID#
Policy#
Group#
Policy holder name and DOB
Front of the insurance card
Back of the insurance card
Signature*
Date:

MonthDayYear
Date

Patient Annual Update form - Acknowledge receipt of policies
These policy forms were provided in the new patient paperwork. If you have not received these policy forms or need a new copy, you can request these upon checkout. Alternatively they can be downloaded from our clinic website:

www.thechildrenscliniccg.com/forms
Click the above link to review the policies below:

HIPAA Acknowledgment: I acknowledge that I have read and been offered a copy of the Notice of Privacy Practices for The Children's Clinic of Conway and Greenbrier.Emergency Room Policy: I have read or been offered a copy of The Children's Clinic of Conway and Greenbrier's Urgent Care and Emergency Room Referral Policy.Financial Policy: I have read or been offered a copy of The Children's Clinic of Conway and Greenbrier's Financial Policy.Missed Appointment Policy: I have read or been offered a copy of The Children's Clinic of Conway and Greenbrier's Financial Policy.
Consent to Treat:
I, caregiver*, parent or legal guardian of child's name, do hereby consent to any medical care necessary for the welfare of my child to be provided by The Children’s Clinic of Conway and Greenbrier. This authorization will be effective indefinitely unless otherwise specified.
Apply the above to the following siblings:
Name and DOB
Name and DOB
Name and DOB
Name and DOB
Signature*
Date:

MonthDayYear
Date
Token:
Click button to update the photo of your child in the medical record
Should be Empty:

THE CHILDREN'S CLINIC OF CONWAY AND GREENBRIER