• PATIENT REGISTRATION FORM

    Required fields have a * next to them
  • Sex*

  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  •  -
  •  -
  • Ok to send texts?*
  •  -
  • Usual provider*

  • Emergency Contact

  • Relationship of emergency contact*

  •  -
  • *

  • Parent or Guardian

  • Guarantor

    Name to whom the statements are sent
  • Guarantor Relationship to Patient*

  • Guarantor Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Is the guarantor's mailing address the same as the patient's above?*

  • Pharmacy Information

    Where you want your prescriptions sent electronically

  • Insurance Information

  • Do you have an insurance plan?*
  • Primary Policy holder's relationship to the patient*

  • Primary Policy Holder's Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Photo of Front of Primary Insurance Card
  • Do you have a secondary insurance plan?*
  • Secondary Policy holder's relationship to the patient*

  • Secondary Policy Holder's Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Photo of Front of Secondary Insurance Card

  • PRIVACY AND TREATMENT CONSENT

    Revised April 2020

  • Consent To Treat And/Or Release: I hereby authorize All-Star Pediatrics, PLLC and its providers to examine and treat me and/or my minor child when necessary. I also authorize the release of my/our protected health information (PHI), acquired in the course of examination to carry out treatment, payment and healthcare operations (TPO) on our behalf. This consent shall remain in effect until revoked in writing.

  • Date Consent to Treat Signed
     / /
    2 digit month, 2 digit day, 4 digit year

  • FINANCIAL AND PAYMENT POLICY

    Revised 4-16-2020

  • Please read this document in its entirety to understand how payments are to be provided for services at our office. We hope this document will help make this process easier to understand. You are welcome to a copy of this document at any time. If you have specific questions, please ask to speak with our office manager.

    Your responsibilities as a patient/family:

    • Understand that payment for medical services and supplies is YOUR responsibility. We bill your insurance company as a courtesy. If we are unable to get payment from your insurance company, the bill is YOUR responsibility to pay.
    • Ensure that you provide us with complete, up-to-date insurance information on ALL policies your child has, at each visit.
    • Notify us of address and phone number changes when you come for a visit.
    • Bring your child’s insurance card and your photo ID to every visit.
    • Contact your insurance company if they request it – i.e. to notify them of secondary insurance plans.
    • Understand your insurance benefits – what is covered, what is not. Unfortunately, we cannot know this about every policy.
    • Pay any copay due at each visit.
    • Pay any deductible or coinsurance within 30 days of being billed.
    • Pay for all services at the time of the visit, if you do not have insurance.
    • Understand that if you change or cancel your plan AFTER being seen for an office visit, you may be responsible for the ENTIRE cost of the visit – including vaccine charges.
    • Notify your insurance company when a new child is born to add them to your plan within 30 days of birth.
    • Keep your AHCCCS plan current (if you have one) or you may be responsible for visit charges.
    • Understand that charges for outside services (send-out lab and x-ray) will be billed separately by that company.
    • Understand that delinquent accounts may be referred to collections; you will be responsible for the addition of collection agency charges (which are equal to the amount sent to collections, thus doubling the original charge.)

    Our responsibilities as your child’s providers regarding payment of services:

    • Bill your insurance company or companies for services provided.
    • Provide an accurate accounting of the bill for services provided. If we do make an error, we’ll correct it as quickly as possible.
    • Follow up with your insurance company to address issues regarding the bill.
    • Provide you with itemized billing statements when requested.
    • Help you understand the explanation of benefits from your insurance company regarding payment.
    • Provide various ways for you to pay your bill – by mail, online, over the phone, or in person; by cash, check or credit card.
    • If you are due a refund for an overpayment you made, provide you with a refund upon request or during our regular review of overpaid accounts.
    • Refer accounts to the collection agency only as a last resort (basically only if you refuse to settle your account

    I have read, understand, and agree to the above Financial and Payment Policy. I authorize my/my child’s insurance benefits to be paid directly to All-Star Pediatrics PLLC.

    I understand that in the unfortunate event that my account becomes delinquent, the account will be transferred to an outside collections agency. I agree to pay all costs of collections, and reasonable attorney’s fees, if incurred. I also understand that this may be grounds for the patients on my account to be discharged from the practice.

    I also authorize All-Star Pediatrics PLLC to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim. If I have any questions regarding this Financial and Payment Policy or my account status, I can call the office at 480-832-0480 to discuss or make arrangements for payment.

  • Date Financial Policy Signed
     / /
    2 digit month, 2 digit day, 4 digit year

  • YOUR CHILD'S HEALTH HISTORY

  • Birth and Pregnancy History

  • Complications during pregnancy

  • Medication use in pregnancy


  • Birth and delivery information

  • Where was the baby delivered?

  • Type of delivery

  • Any delivery complications?

  • Problems during the newborn hospital stay

  • During the hospital stay

  • FAMILY HEALTH HISTORY

    Parents, siblings, and grandparents (if it pertains directly to the children)
  • Any of the following health issues with family members?

  • Social History

  • Your child's diet*

  • How's the school performance?
  • Exercise level
  • Home situation*

  • Childcare*
  • Is the child exposed to secondhand smoke?*
  • Are there any animals at home?*

  • Are seatbelts routinely used?*

  • Child's Past Medical History

  • Please check any health problems in the child's history*

  • Previous surgeries

  • Allergies to medications?*
  • Allergies to foods?*
  • Are your child's vaccinations up to date?*
  • Should be Empty: