Patient Contact Information
Date:________________
Child’s Name: Nickname:
Last First MI
Date of Birth:
Insurance Information We will need a copy (front and back) of your insurance card(s) before your first visit
Insurance Co:
1 - Primary Policy Holder Information
Insured Name DOB: Relationship to patient:
Insured Address if different than given: Email:
City St Zip Ph#
2 – Other Policy Holder Information (if you have secondary or sibling has another insurance)
Insured Name DOB: Relationship to patient:
Insured Address if different than given: Email:
City St Zip Ph#
Parent Contact – This person receives messages and calls concerning appointments, medical issues, and billing and lives at the
address you gave during patient registration.
Parent (or Guardian): Relationship to pt:
Address if different than address given: City St Zip
Ph# Email:
Person responsible for payment if there is a balance on the account (Copay are due at the time of visit)
Financially Responsible Person: Relationship to pt:
Address if different than given: City St Zip
Ph# Email:
Patient Records: May all contacts you listed during registration have access to patient’s records? Y N If No, list those you
permit to have access:
If parents are divorced or separated: Who has custody? Are there legal restrictions preventing non-
custodial parent from consenting to medical treatment for the patient or obtaining patient’s medical treatment? Y N. If yes,
please explain and provide a copy of legal paperwork supporting this restriction:
If guardian is not the biological parent, provide a copy of legal guardian documents
Siblings (who are patients at The Pediatric Place)
First Name Last name DOB Which policies above? Gender
Authorization for Medical Care
I authorize the following people to bring my child in for, and consent to, treatment, or receive medical advice over the phone if they
are taking care of my child in my absence. This does not allow them to have access to confidential health information that is not
relevant for the visit. Please check the boxes to give them additional specific authorizations.*
Name: Relationship: □ May pick up prescriptions
□ May pick up shot records
Name: Relationship: □ May pick up prescriptions
□ May pick up shot records
*Any other documents to be accessed up by non-legal guardians must have written consent.
I understand telephone triage and advice services will be extended to the above persons if regarding direct patient care while the
child is in their care. In the absence of written authorization for medical services, our office will try to reach you for verbal
authorization. If we cannot reach you, we will not refuse treatment. This serves as consent for medical treatment we deem as
medically necessary and appropriate.
Parent /Guardian Signature Date Relationship to pt
I have been given an opportunity to read the practice’s HIPPA Notice of Privacy Practices and I am entitled to a personal copy if I ask
for one.
✓ Parent /Guardian Signature Date:
Financial and Billing Policy
Although we make every attempt to understand your coverage, understanding your health insurance policy is your
responsibility. Your insurance plan determines your benefits, copays, and deductibles. Any questions concerning your
policy should be directed to your insurer.
If you have multiple insurance policies on your child, we will need copies of all insurance cards and you will need to file a
Coordination of Benefits with all insurers.
Copays and outstanding balances are due at the time of an appointment.
We email and text notice when you have a balance due. From these messages, you can link to view the statement and
pay your balance. Outstanding balances not paid within 60 days are subject to $25.00 late fee and collections. Even if
you do not receive a statement from us, you are still responsible for your balance. We recommend reviewing your
insurance EOBs to confirm patient responsibility, which is the balance you will owe us for a visit.
✓ I understand the above Financial and Billing Policy. Sign:
Newborn Insurance Reminder
✓ You have 30 days from the date of birth to update newborn insurance coverage. If you do not have active
coverage for your newborn at the one month visit, we will ask you to pay for all hospital and office visits as well
as any procedures performed (such as circumcision or frenotomy). Your fees could range from $110 to $700.
When adding your baby, confirm we are an in-network provider and the eligibility date begins on your baby’s date of
birth. If you have an HMO, ACA or Medicaid plan, make sure Dr. Bergman or Dr. Hlobik is the PCP (Primary Care
Provider).
✓ I understand I need to enroll my newborn in an insurance plan with 30 days of birth. Sign:
