• Insurance

    Essex Pediatrics • 89 Main Street, Essex Junction, VT 05452 • (802) 879-6556

  • Patients

    List the name and date of birth for each child in your family who is a patient.

  • Patient 1 Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Patient 2 Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Patient 3 Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Patient 4 Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Patient 5 Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Patient 6 Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year

  • Primary Insurance

  • Do you have primary insurance?*
  • Subscriber's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • To expedite your benefits confirmation, please upload a copy of the front and back of your insurance card, as well as the front of the subscriber's photo ID. You can use your mobile phone to take these photos.

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  • Secondary Insurance

  • Do you have secondary insurance?*
  • Subscriber's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Start Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • To expedite your benefits confirmation, please upload a copy of the front and back of your insurance card. You can use your mobile phone to take these photos.

  • Browse Files
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    Choose a file
    Cancelof
  • Browse Files
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  • Medicaid

  • Insurance Authorization and Assignment (Please Read and Sign)

    I attest that the information I have given here is correct and true to the best of my knowledge. I hereby assign benefits to be paid directly to the doctor, and authorize him/her to furnish information regarding my visits to my insurance carrier. I understand that I am responsible for my entire bill unless this form is complete.

    During a preventative care visit, if we address additional problems, topics, or concerns, or we address any ongoing chronic medical conditions, we must also document and claim these problems to your insurance company. Depending on your insurance, these additional problems will often be subject to co-pays and deductibles, so you may receive an additional bill for this service. Please see our website for more information. 

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: