New Patient Registration form

New Patient Registration form

Thank you for Completing in Full
Patient Information
Date

MonthDayYear
Date
Child’s Full Name

First NameLast Name
Date of Birth

MonthDayYear
Sex

Other
Race

Other
Ethnicity
Siblings
Address

Street Address (include Apt/Unit if applicable)

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Pharmacy Information
Preferred Pharmacy Name
Pharmacy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Pharmacy Address
Pharmacy Zip
Parent/Guardian Information
Parent/Guardian #1 Full Name

First NameLast Name
Parent/Guardian #1 Date of Birth

MonthDayYear
Date
Parent/Guardian #1 Social Security Number
Parent/Guardian #1 Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #1 Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #1 Email
example@example.com
Parent/Guardian #1 Driver's License

Driver's License NumberState
Parent/Guardian #1 Occupation
Parent/Guardian #1 Employer
Single parent / No second parent or guardian to list
Parent/Guardian #2 Full Name

First NameLast Name
Parent/Guardian #2 Date of Birth

MonthDayYear
Date
Parent/Guardian #2 Social Security Number
Parent/Guardian #2 Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #2 Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #2 Email
example@example.com
Parent/Guardian #2 Driver's License

Driver's License NumberState
Parent/Guardian #2 Occupation
Parent/Guardian #2 Employer
Permission to leave messages on all phone contacts listed above?
Family Information
Child’s Parents Are

Other
Emergency Contact
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Information
Parent #1 Insurance Company
Parent #1 Insurance Address
Parent #1 Policy Holder Name
Parent #1 Policy Holder DOB

MonthDayYear
Date
Parent #1 Policy ID Number
Parent #1 Group Number
Please upload a photo/screenshot of the front of your insurance card.

Cancelof
Please upload a photo/screenshot of the back of your insurance card.

Cancelof
Check here if your child is older than 30 days to skip the next section
If both parents carry different health insurance plans, we kindly ask that you provide both insurance cards. We are required to bill the parent whose birthday (month & day) comes first in the calendar year if your child is under 30 days old.
Parent #2 Insurance Company
Parent #2 Insurance Address
Parent #2 Policy Holder Name
Parent #2 Policy Holder DOB

MonthDayYear
Date
Parent #2 Policy ID Number
Parent #2 Group Number
Please upload a photo/screenshot of the front of your insurance card.

Cancelof
Please upload a photo/screenshot of the back of your insurance card.

Cancelof
Primary Patient Policy for Child Over 30 Days Old
IT IS YOUR RESPONSIBILITY TO NOTIFY US OF ANY CHANGES TO YOUR INSURANCE INFORMATION.
Birth History
Place of Birth
Birth Weight
Birth Type
Delivery Type
Any problems at birth? (e.g., jaundice, extended hospitalization, NICU)
Medical History
Please check the box below if your child is a newborn and does not have any significant past medical history.
Past Medical History (if applicable)
Chronic Illnesses
Hospitalizations
Surgeries
Does your child see any specialists? (other doctors or therapists)
Allergies
Medication Allergies
Food Allergies
Other Allergies (environmental/pets/etc.)
Current Medications
Current Medications and Reason
Family History
Significant Family Medical History (e.g., type 1 diabetes, heart disease, seizure disorder, allergies, etc.)
Medical Consent & Office Policy Agreement
Hours of Operation:

Monday–Friday 9:00am–5:00pm

Saturday–Sunday 9:00am–3:00pm (Beverly Hills Office, by appointment only)

Parking is available in the building Monday through Friday. Street parking is also available in the surrounding neighborhood. Please read parking signs carefully and allow adequate time to arrive for your appointment.

If you have a question, please call during office hours. If you need to speak with your doctor, your call will be returned between patients, during lunch, or after 5:00pm. When the office is closed, a nurse triage service and one of our doctors are always available by phone. Please reserve after-hours calls for urgent matters that cannot wait until the next business day.

Visit our website at www.beverlyhillspediatrics.com for helpful information on common illnesses and medication dosing charts.
Financial Policies
We will bill your primary insurance company after each visit. It is your responsibility to keep your insurance and personal information current. Copays are due at the time of service, per your agreement with your insurance provider. After your visit, once charges are processed by your insurance, you will receive a billing statement. Any balance not covered by insurance is your responsibility and is due upon receipt. Statements are issued on the third of each month. A $25.00 late fee will be added every 30 days for unpaid balances.

EZ Pay Option: For ease of payment, we recommend our EZ pay option. Your credit card will be kept on file and your balance will be automatically charged on the 15th of each month. You will still receive a statement. Please complete the EZ Pay Agreement form to opt in.

We do not verify insurance coverage. Please contact your insurance carrier to confirm participation and coverage details. While we are happy to submit claims on your behalf, accurate and updated information is your responsibility. Please notify us of any changes to your insurance, address, or phone number. Reminder: Newborns must be added to your insurance plan within the first 30 days after birth.

The Beverly Hills Pediatrics Annual Family Fee is due June 1st each year and will be prorated during your first year.

For billing questions, contact: billing@beverlyhillspediatrics.com
Appointments
To help us stay on schedule, please arrive 15 minutes prior to your appointment. Patients arriving more than 15 minutes late may need to be rescheduled. For well-child visits, we recommend scheduling 2 - 4 months in advance to secure your preferred date and time. Please allow at least two weeks for completion of school or camp forms.

All visits—including sick visits—must be scheduled. Same-day sick appointments are available. A $75.00 fee will apply for walk-ins without a scheduled appointment. We have two entrances—please use the “not so well” entrance when your child is sick.

Failure to attend a scheduled well-child visit or cancellations made within 24 hrs will result in a $95.00 fee.

Emergency: If your child is experiencing a life-threatening emergency, call 911 or go to the nearest emergency room.
Medical Consent & Office Policy Agreement Acknowledgement of Receipt of Notice of Privacy Practices
Medical Consent & Office Policy Agreement Acknowledgement of Receipt of Notice of Privacy Practices

I hereby authorize examination and any services deemed necessary by Beverly Hills Pediatrics. I have read and understand the office policies and authorize all insurance benefits to be paid directly to Beverly Hills Pediatrics for services rendered. I understand that I am responsible for all charges as determined by my insurance company (including deductibles, coinsurance, and copays), as well as any services not covered by insurance. These may include, but are not limited to, the annual family fee, in-office medications, telephone consultations, missed appointment fees, and finance charges on outstanding balances. I authorize Beverly Hills Pediatrics to release medical information to my insurance company when necessary. I also acknowledge receipt of the Notice of Privacy Practices, which explains how my child’s medical information may be used and disclosed, and how I may access this information. To support environmentally friendly practices, I understand this information is available online at www.beverlyhillspediatrics.com, and a printed copy will be provided upon request.
NOTICE TO CONSUMERS
Medical doctors are licensed and regulated by the Medical Board of California
(800) 633-2322
www.mbc.ca.gov
Name of Parent/Guardian
Signature
Date

MonthDayYear
Annual Administrative Fee Agreement
I agree to the Beverly Hills Pediatrics Administrative Fee.

The cost of the annual administrative fee is:

If your youngest child was born in 2016 or earlier:
$395 for one child $475 for families with two or more children

If your youngest child was born in 2017 or later:
$565 for one child
$595 for families with two children
$625 for families with three or more children

This fee is due in full by June 1st of each year.
We would like to thank all of our patients for your continued support and trust in our practice. We are committed to providing the highest quality care for your children.
I agree to the Beverly Hills Pediatrics Administrative Fee as described.
Printed Name
Signature
Date

MonthDayYear
Child’s Full Name

First NameLast Name
Siblings
EZ Pay Consent
Dear Parents,

Beverly Hills Pediatrics strongly prefers the use of automatic debit services for convenient payment of your statements. Please complete this form and return it to our office. Your family statements will continue to be mailed monthly.

PATIENT EZ PAY CONSENT FORM
I authorize Beverly Hills Pediatrics to charge the credit card listed below for balances not paid or covered by my insurance carrier. My family balance will be charged on the 15th of each month, beginning the first 15th after the date of my signature.

I understand this authorization will remain valid through the expiration of my credit card unless I cancel it in writing.
Cardholder Name
Guarantor Account Number (to be completed by BHP office staff)
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Card Type
Card Number
Expiration Date
CVV
E-mail (for contact)
example@example.com
Child’s Full Name

First NameLast Name
Siblings
Card User's Authorized Signature (EZ Pay)
Date (EZ Pay)

MonthDayYear
Email Consent
TRANSFER AND CORRESPONDENCE OF YOUR CHILD’S HEALTH CARE INFORMATION VIA EMAIL

PLEASE NOTE:
You must provide your consent, recognizing that email is not a secure form of communication. There is some risk that individually identifiable health information and other sensitive or confidential information contained in such email may be misdirected, disclosed, or intercepted by unauthorized third parties. We will use the minimum necessary amount of protected health information to respond to your request. Transmissions are not encrypted.
REQUEST CONSENT FORM

I authorize Beverly Hills Pediatrics and its physicians and staff to correspond with me via the email address provided below. This consent applies to all children for whom I am the parent or legal guardian and who are patients of Beverly Hills Pediatrics, including any children currently in the practice or added to the practice in the future. This consent will remain in effect until I notify Beverly Hills Pediatrics in writing to discontinue.
Your Name
Relationship to Child
Child’s Full Name

First NameLast Name
Siblings
Email Address
example@example.com
Signature
Date

MonthDayYear
Date
Use of AI-Assisted Documentation
To help improve the accuracy and efficiency of clinical documentation, Beverly Hills Pediatrics may use an AI-assisted medical scribe during patient visits. The AI scribe listens to and processes information discussed during the visit to generate clinical notes for review and approval by your healthcare provider. No medical decisions are made by the AI system.
Signature
Date

MonthDayYear
Date
Does your child need newborn screening records requested from the California Department of Public Health?
Should be Empty:

New Patient Registration form

Patient Information

Preferred Pharmacy Information

Parent/Guardian Information

Family Information

Emergency Contact

Insurance Information

Birth History

Medical History

Past Medical History (if applicable)

Allergies

Current Medications

Family History

Medical Consent & Office Policy Agreement

Financial Policies

Appointments

Medical Consent & Office Policy Agreement Acknowledgement of Receipt of Notice of Privacy Practices

NOTICE TO CONSUMERS

Annual Administrative Fee Agreement

EZ Pay Consent

Email Consent

Use of AI-Assisted Documentation