Family Information Form
Please fill out your family information below.
Click all that apply
Name Change
Phone Change
Address Change
Guardian #1
Mother
Father
Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DOB
-
Month
-
Day
Year
Date
Employer
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Guardian #2 (If Applicable, or hit next)
Mother
Father
Other:
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DOB
-
Month
-
Day
Year
Date
Employer
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Next
Preferred Provider
Dr. Bob Lindsay
Dr. Ryan Lindsay
Preferred Appointment Reminder
Text
Call
Phone Number
Please enter a valid phone number.
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Please list children oldest to youngest.
Child's Name
First Name
Last Name
Gender
Male
Female
DOB
-
Month
-
Day
Year
Date
Primary Insurance
Secondary Insurance
Medicaid Nummber
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2nd Child's Name (If applicable or hit next)
First Name
Last Name
Gender
Male
Female
DOB
-
Month
-
Day
Year
Date
Primary Insurance
Secondary Insurance
Medicaid Nummber
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Next
3rd Child's Name (If applicable or hit next)
First Name
Last Name
Gender
Male
Female
DOB
-
Month
-
Day
Year
Date
Primary Insurance
Secondary Insurance
Medicaid Nummber
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Next
More than 3 children to register? Please fill out box with name, gender and DOB below. Or hit next.
Back
Next
Primary Insurance Information (Please give your insurance card to the Receptionist)
Name of Carrier
Policy Holder
Policy Holder DOB
-
Month
-
Day
Year
Date
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Seconday Insurance Information (Please give your insurance card to the Receptionist)
If applicable. If not hit hext.
Name of Carrier
Policy Holder
Policy Holder DOB
-
Month
-
Day
Year
Date
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Are all family members covered? If not, specify those not covered:
Yes
No
If no, please indicate which children are not covered. Or hit next.
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Emergency Contact
(List additional persons who may bring children for appointments or who we are authorized to communicate with for medical information)
Emergency Contact #1
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relationship to patient(s)
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Emergency Contact #2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relationship to patient(s)
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ASSIGNMENT OF INSURANCE BENEFITS/ CONSENT TO TREAT/ PRIVACY POLICY
Please check boxes for acknowledgement and consent.
I understand that I am financially responsible for all professional charges that my children may incur.
All copayments and non-covered charges are due at time of service. All costs not paid by insurance are due upon receipt of statement.
I hereby authorize payment of medical benefits direct to Advanced Pediatric Associates. I further authorize the release of any medicalinformation necessary for processing the insurance claim. I understand that all costs not paid by insurance are my responsibility unlessotherwise prohibited by state or federal regulations.
Permission to Treat Minor (under age 18): In the event of an emergency and I cannot be contacted, I give my permission to AdaPediatrics to treat my child in their office as required by the events of that emergency situation.
Acknowledgement of receipt of HIPAA Notice of Privacy Practices: I have received or have been given the opportunity to receive a copy ofHIPAA Notice of Privacy Practices for Ada Pediatrics.
Parent/Guardian Signature (Patient Signature if 18 or older)
Name
Date
-
Month
-
Day
Year
Date
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Should be Empty: