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NEW PATIENT REGISTRATION FORM

For your convienence, print and complete the registration form to expedite new patient registration at your first visit.

Referred By: ________________________

PATIENT REGISTRATION / INFORMATION

Patient Name: ______________________________Date of Birth____________
Address:___________________________________
City_____________________State______________Zip_____________
Telephone#_______________ Cell# _______________
Social Security# (if known)_______________Email address_________________

Allergies No Yes (please list) ________________________________

Emergency Contact_________________Telephone__________________Relation___________

PARENT INFORMATION

Mother’s Name________________________ Father’s Name ___________________________
Address______________________________ Address_________________________________
Telephone # __________________Telephone# ________
Cell/Beeper#__________________________ Cell/Beeper#_____________________________ Employer_____________________________Employer________________________________
Address:________________________ _____Address_________________________________
Social Security #____________________Social Security # _____________________
DOB: ______________________________ DOB:____________________________________
Email_______________________________ Email____________________________________

INSURANCE
PRIMARY SECONDARY N/A YES
Insurance Company____________________ Insurance Company________________
Policy Holder_________________________ Policy Holder_____________________
DOB_____________ ID#_______________ DOB___________ ID#______________
GRP#_______________________________ GRP#____________________________
Employer_____________________________ Employer________________________

INFORMATION AND ASSIGNMENT OF BENEFITS
I authorize the release of any medical information necessary to process this claim. I permit a copy of this authorization to be used in place of the original. The authorization may be revoked by either me or my insurance company at anytime in writing.
I hereby authorize BEACH PEDIATRICS to apply for benefits on my behalf for covered services rendered by or ordered by. I request that payment from my insurance company be made directly to my physician with BEACH PEDIATRICS.
I certify that the above information is true and correct and that I have received and understand the HIPAA privacy form.

Date_____________________Signature____________________________________________

Other pages:

Beach Pediatrics is a division of Allied Pediatrics of New York

OFFICE HOURS

ABOUT OUR PHYSICIANS

Allied Pediatrics
Learn about Allied Pediatrics and our after hours care here
HIPAA STATEMENT

NEW PATIENT REGISTRATION FORM

NEW PATIENT OFFICE POLICY SIGNATURE FORM

NEW PATIENT RECORD RELEASE AUTHORIZATION

EDUCATION - Colic, Constipation, Bottle/Breast Feeding

HELPFUL LINKS / Vaccines, Acd. of Peds, Car Seat Guidelines, Centers for Disease Control & Prevention

NEWS LETTERS

PATIENT SURVEY

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