Pediatric Patient Registration - Galen Medical Group

Pediatric Patient Registration - Galen Medical Group

The Allergy & Asthma Group of Galen
Patient Name

First NameMiddle NameLast Name
Patient's Gender

FemaleMale
Name your Child Goes by
Child's Age
Date of Birth

MonthDayYear
Social Security Number
Current Primary Physician
Child's Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
How did you hear about us?

RadioTVBillboardMagazineOther

Pediatric Patient Registration - Galen Medical Group

Parent(s)/Guardian(s) Information
Relationship to child

MotherStep-motherGuardian
Parent/Guardian's Name

First NameMiddle NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Current Employer
Occupation
Email
example@example.com

Pediatric Patient Registration - Galen Medical Group

Parent(s)/Guardian(s) Information
Relationship to child

FatherStep-fatherGuardian
Parent/Guardian's Name

First NameMiddle NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Current Employer
Occupation
Email
example@example.com

Pediatric Patient Registration - Galen Medical Group

Consent for Release of Medical Information
Signature*

Clear
Authorized Person

First NameLast NameRelationship
Authorized Person's Phone Number

Area CodePhone Number
Authorized Person

First NameLast NameRelationship
Authorized Person's Phone Number

Area CodePhone Number
Authorized Person

First NameLast NameRelationship
Authorized Person's Phone Number

Area CodePhone Number
Pediatric Patient Registration - Galen Medical Group

Consent for Medical Treatment
Signature*

Clear
Authorized Person

First NameLast NameRelationship
Authorized Person's Phone Number

Area CodePhone Number
Authorized Person

First NameLast NameRelationship
Authorized Person's Phone Number

Area CodePhone Number
Authorized Person

First NameLast NameRelationship
Authorized Person's Phone Number

Area CodePhone Number
Please list any siblings who are also patients of ours.
Patient's sibling, who are also patients of ours.

First NameLast NameRelationship
Patient's sibling, who are also patients of ours.

First NameLast NameRelationship
Patient's sibling, who are also patients of ours.

First NameLast NameRelationship
Pediatric Patient Registration - Galen Medical Group

Advanced Directives & Authorization
I AGREE TO NOTIFY GALEN MEDICAL GROUP, IN WRITING, IF THERE ARE ANY CHANGES IN THE PERSON(S) AUTHORIZED.
I authorize Galen Medical Group to release to my insurance company, managed care organization, state agency(ies), federal agency(ies), Health Care Financing Administration, Third Party Administrators, and/or Workers’ Compensation or its agents any information needed to process my claim and/or determine benefits payable for related services. I also authorize Galen Medical Group to utilize a fax machine to transmit any or all of the above medical records pertaining to my medical care or insurance reimbursement. I acknowledge that faxing my medical records may increase the risk of accidental disclosure of my medical records.

I grant permission to Galen Medical Group to release all or part of my medical record to any consulting entity that may be involved in my medical care. This includes, but is not limited to, testing facilities, consulting physicians, and outpatient facilities.

I understand that I am financially responsible for deductible amounts, co-payments, co-insurance amounts, non-covered charges and any and all balances not covered under a contractual write-off agreement between Galen Medical Group and my third party payer. My carrier’s failure to pay does not release me from this responsibility. I also agree that should this account be turned to collection, I will be responsible for all costs associated with debt collection, including attorney fees and court costs.
Signature*

Clear

Should be Empty: