WESTFIELD PEDIATRICS

PATIENT REGISTRATION FORM

Today’s Date_______________

PATIENT INFORMATION

Name:  Last________________________First________________Middle___________

Birth date____________________            Sex_______

Address___________________________Town_______________Zip_______

Home Phone (     ) ____________________________

Siblings Names with Birthdates_____________________________________________

PARENT INFORMATION

Mother’s Name_____________________        Father’s Name______________________

Mother’s Date of Birth______________           Father’s Date of Birth_______________

Mother’s SS#_______________________      Father’s SS#________________________

Address___________________________       Address____________________________

Employer___________________________     Employer__________________________

Home Phone (    )__________________          Home Phone (     )___________________

Employer Phone (    )_________________      Employer Phone (    )_______________

Cell Phone (    )____________________        Cell Phone (     )___________________

  INSURANCE INFORMATION

Subscriber’s Name__________________________  SS#______________________

Insurance Company__________________________ Ins Co Phone (    )___________

Insurance Co Address__________________________________________________

Insurance ID#_____________________________ Insurance Group #____________

Insurance Effective Date_____________________

HEALTH SAVINGS ACCOUNT INFORMATION

If you have a health savings account or High Deductible Plan, please provide a copy of your HSA card or a personal credit card that we may keep on file. By signing below, you agree to have your card billed for any non-covered services.

HSA Plan Name_____________________

Card # ____________________________

Name on Card___________________________

Effective Date ___________________

Expiration Date ___________________

Today’s Date_____________                  Signature__________________________

CREDIT CARD INFORMATION

Please provide us with credit card information that we may bill for services that are deemed to be patient responsibility.  Your card will not be billed until we have received your insurance company EOB.

Credit Card____________________

Credit Card #________________________

Name on Credit Card________________________

Expiration Date_________________________

I authorize Westfield Pediatrics to charge my credit card for services that are not covered by my insurance company.

Date_______________                 Signature________________________

I authorize the release to any referring physician or appropriate insurance company any medical information related to my child’s examination and treatment.  I understand that I am financially responsible for any co-pay, deductible, co-insurance and non-covered expenses.