the-pediatric-center.com - Demographic Form

Insurance Information
Patient's Name:

First NameLast Name
DOB:

MonthDayYear
Date
Is this patient covered by a commercial Insurance? (please select one)

YesNo
(Such as: Blue Cross/ Blue Shield – Cigna – Aetna – United Healthcare – Humana or others)
Section A
Name of Primary Insured Member (The parent or guardian who provides the insurance)

First NameLast Name
DOB

MonthDayYear
Date
SS#
Name of the Insurance Company:
Amount of Copayment $
Patient's Member ID #:
Group #:
Employer of Primary Insured
Relationship to Patient
Section B
If the Patient has Insurance Coverage through Medicaid or Peach Care for Kids Please complete below
Which Type of Insurance is the patient covered by? (Please Select one)

Peach StateAmerigroupWellCareCareSourceStraight Ga Medicaid
Member ID Number :
(This Number is 12 digits long and usually starts with 222 or 111 )
CMO Member ID Number : :
This is a shorter number for people with Amerigroup, WellCare or CareSource.
Remember that you must have us listed as your PCP (primary care provider) with your Insurance Company.
Ask us if you do not know how to make this change.

Authorization and Consent Section
Patient's Name

First NameLast Name
DOB

MonthDayYear
Date
Initial I give The Pediatric Center of Stone Mountain, LLC permission to evaluate and treat my child. I understand that there will be written, oral and electronic communication between care providers, insurance companies and employees. I understand that all practices of confidentiality will be followed when using information gathered.
Initial I give The Pediatric center of Stone Mountain, LLC permission to submit bills directly to the insurance carrier.
InitialI have checked with my child's Healthcare Plan before this appointment to confirm my financial responsibilities.
InitialI have read and agree to follow The Pediatric Center of Stone Mountain, LLC Office, Appointment, Missed appointment and Financial policies.
Patent/ Guardian signature:

Clear
Date

MonthDayYear
Date
Emergency Medical Release
In the event your child needs emergency medical attention while on our property and in our care, we will need your permission to provide such emergency medical attention. Please read and sign the statement below.
As the legal guardian of (child's Name) I give my permission for The Pediatric Center of Stone Mountain, LLC to contact emergency personnel in the event of a medical emergency.
Patent/ Guardian signature:

Clear
Date

MonthDayYear
Date

Who has permission to seek medical care for this patient ?

Emergency contact Information:

Patient Demographic Information