Registration Form

Registration Form

115 Norwood Park South, Suite 110, Norwood, MA 02062

(p): 781-769-4090, Fax: 781-769-6485

122 Grove Street, Franklin, MA 02038

(p): 508-528-5404, Fax: 508-528-5383

Which office location do you prefer?

Parent 1:

First NameLast Name

Relationship to patient:

Date of Birth:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home

Area CodePhone Number

Cell

Area CodePhone Number

Work

Area CodePhone Number

E-mail

Occupation:

Parent 2:

First NameLast Name

Relationship to patient:

Date of Birth:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home

Area CodePhone Number

Cell

Area CodePhone Number

Work

Area CodePhone Number

E-mail

Occupation:

Primary Insurance:

Insurance Name

Insurance Medical Claims Address (on back of card)

Subscriber NumberSubscriber Name

Secondary Insurance (if applicable):

Insurance Name

Insurance Medical Claims Address (on back of card)

Subscriber NumberSubscriber Name

Child 1:

First NameLast Name

Date of Birth:

Sex

Special Needs:

Race:

Hispanic Y/N:

Birth Country (Ethnicity):

Child 2:

First NameLast Name

Date of Birth:

Sex

Special Needs:

Race:

Hispanic Y/N:

Birth Country (Ethnicity):

Child 3:

First NameLast Name

Date of Birth:

Sex

Race:

Hispanic Y/N:

Special Needs:

Birth Country (Ethnicity):

Child 4:

First NameLast Name

Date of Birth:

Sex

Race:

Hispanic Y/N:

Special Needs:

Birth Country (Ethnicity):

Primary Language:

Preferred Pharmacy Name & Address:

Choice of new PCP or Practice Provider

Any Additional Comments:

Please Note: this office does not do third party billing to ex-spouses or other individuals. Whichever parent/guardian brings the child to the office is responsible for any outstanding deductibles, co-payments, co-insurances, or bills due to lapses in insurance coverage. There are no exceptions.

I authorize payment of medical benefits to the physician or supplier of PEDIATRIC ASSOCIATES OF NORWOOD AND FRANKLIN, P.C. for services rendered during my child(ren)'s examination and/or treatment. I also authorize my child(ren)'s physican to release any information acquired in the course of their examination and/or treatement to my insurance company to determine these benefits or the benefits payable for related services.

By signing below, I indicate that I have read and understand all the information on this form. Any information that I have entered is, to the best of my knowledge, correct.

Signature

Date

MonthDayYear

Please click, "Submit to Pediatric Associates" to send electronically, or print this form and deliver it to our office.