Preferred Pediatrics, Pediatrics with a Mother's Touch

Child information

Your child's basic details.

First name*

Middle

Last name*

Date of birth*

Sex*

Primary phone (optional)

Mailing address*

City*

State*

Zip*

Race (optional)

Hispanic or Latino?

Siblings (optional)

Mother / guardian

Social security numbers are collected in person at check-in, not online.

Include mother or guardian details

Full name

Date of birth

Same as child's address

LA

Home phone

Cell phone*

Work phone

Employer

Email*

We send your confirmation and a copy of your signed forms here.

Genetic mother

Father / guardian

Social security numbers are collected in person at check-in, not online.

Include father or second guardian details

Insurance

We just need the basics online. Please bring your insurance card to your first visit. We will copy the policy and group numbers then.

Who is the primary policy holder?

Using the details entered above. Change the parent details above and this updates automatically.

Insurance company*

Emergency contact & preferences

Quick fill:

Emergency contact name*

Relationship*

Daytime phone*

Cell phone

How did you hear about us?

Appointment reminders by

Contact parent

Authorized to bring your child

People (other than the parents/guardians above) who have your permission to bring your child in and to sign for injections or immunizations.

Office policies acknowledgement

Commercial health insurance.

As a courtesy, the physicians at Preferred Pediatrics LLC will file claims for healthcare services provided on my behalf directly to my health insurance carrier as long as my account remains in good standing. I hereby assign directly to the physicians any and all health insurance benefits to which I am entitled and which are payable to me for any services rendered.

No insurance or limited coverage.

If I have no insurance or limited coverage for the charges incurred on this account, I agree to pay the full balance of such charges at the time of service or in accordance with payment terms agreed upon by Preferred Pediatrics LLC. I am responsible for determining whether the services of Preferred Pediatrics LLC are covered by my insurance contract, for verifying that my correct insurance and contact information is on file, and for promptly notifying Preferred Pediatrics of any changes. Well visits, immunizations and any other charges denied by my insurance carrier are my financial responsibility.

Release of information.

I authorize Preferred Pediatrics LLC to release any and all medical information which may be requested by my insurance company to process insurance claims and remit payment, or which may be necessary in coordinating medical care with specialists or other healthcare professionals in the course of treatment. I authorize the use of my signature below on all insurance submissions made by Preferred Pediatrics LLC for healthcare services provided.

Scheduling.

I understand that well-visit appointments must be made in advance. I will arrive 5 to 10 minutes earlier than my appointment time and call if I anticipate being late. I will call 24 hours in advance if I need to cancel well visits or rechecks and will give at least two hours notice if I must cancel a sick visit.

NSF charge.

I agree to pay a $25.00 charge on all checks returned for non-sufficient funds.

I have read and agree to the office policies of Preferred Pediatrics LLC.

Signature of responsible party

Sign above with your finger or mouse

By signing you confirm you are authorized to do so.

Printed name of signer

HIPAA notice of privacy practices

By checking below you acknowledge that you have received (or been offered) a copy of the Notice of Privacy Practices of Preferred Pediatrics, LLC. A printed copy is available at the front desk on request.

I acknowledge the Notice of Privacy Practices for Preferred Pediatrics, LLC.Printed name*

Signature

Sign above with your finger or mouse

By signing you confirm you are authorized to do so.

Printed name of signer

Insurance coverage checklist

Please call your insurance company and check whether each of the following is covered by your policy. Fees for services not covered by your insurance contract will become your responsibility.

Well-baby visits covered?

Immunizations covered?

Date coverage was checked

Signature

Sign above with your finger or mouse

By signing you confirm you are authorized to do so.

Printed name of signer

Complete your new patient forms

Child information

Mother / guardian

Father / guardian

Insurance

Emergency contact & preferences

Authorized to bring your child

Office policies acknowledgement

HIPAA notice of privacy practices

Insurance coverage checklist