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.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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.
Format: (000) 000-0000.
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Please list children oldest to youngest.
Child's Name
First Name
Last Name
Gender
Male
Female
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Insurance
Secondary Insurance
Medicaid Nummber
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Next
2nd Child's Name (If applicable or hit next)
First Name
Last Name
Gender
Male
Female
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Insurance
Secondary Insurance
Medicaid Nummber
Back
Next
3rd Child's Name (If applicable or hit next)
First Name
Last Name
Gender
Male
Female
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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.
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Next
Primary Insurance Information (Please give your insurance card to the Receptionist)
Name of Carrier
Policy Holder
Policy Holder DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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
2 digit month, 2 digit day, 4 digit year
Date
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Next
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.
Format: (000) 000-0000.
Relationship to patient(s)
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Emergency Contact #2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to patient(s)
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Next
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
2 digit month, 2 digit day, 4 digit year
Date
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Should be Empty: