PATIENT'S PERSONAL INFORMATION Name: ________________________________________________ SSN: ________________________DOB: ______________________Sex: M or F Address: ____________________________________________________________________________________________________________________
INSURANCE POLICY HOLDER (OR RESPONSIBLE PARTY IF UNINSURED) INFORMATION
Name: ____________________________________________Relationship to Patient: ______________________SSN: ________________________ DOB: ______________________ Drivers License No: ____________________________ State: _______________________________________ Address: ______________________________________________________________________________________________________________ Home Phone: _____________________________Cell Phone: ____________________________ E-Mail: ________________________________ Employer:______________________________________________________________________________________________________________ Employer Address:_____________________________________________________________________________________________________ Occupation: ___________________________ Work Phone: _______________________________O.K. to leave message at work? Y N Primary Health Insurance Company: _____________________________________________________________________________________ ID/ Policy No: ______________________________Group Number: ____________________ Effective Date:___________________________ Secondary Health Insurance Company: __________________________________________________________________________________ ID/ Policy No: ______________________________Group Number: ____________________ Effective Date:___________________________
ADDITIONAL FAMILY INFORMATION
Other Parents Name: ___________________________________________ SSN: _______________________ DOB: ________________________ Employer: __________________________________________________________ Occupation: ______________________________________ Address: _____________________________________________________________________ Phone : __________________________________ IN CASE OF EMERGENCY Emergency Contact: ___________________________________________________________________________________________________ Relationship to Patient: _______________________________Home Phone: ______________________Cell Phone: ____________________ PHARMACY INFORMATION Address: _____________________________________________________________________ Phone : __________________________________ Authorization to Pay Benefits to Sun Pediatrics: I hereby authorize Sun Pediatrics to release any medical information needed to process insurance claims and authorize payments directly to Sun Pediatrics for all medical and surgical benefits. I agree that I am financially responsible on the day of service for any charges not covered by this authorization or not covered by my insurance policy(s).
Parent or Guardian Signature: _________________________________________________Date: ___________________________________