Patient Information

Child's Information

Last Name*

First Name*

Middle Name

Social Security #

Date of Birth*

MM

DD

YYYY

Home Phone*

Address*

Street AddressAddress Line 2CityStateZip Code

Parent or Guardian Information

Last Name*

First Name*

Middle Name

Social Security #

Date of Birth*

Cell Phone

Work Phone

Employer

Occupation

Address same as child

Parent/guardian address same as child

Address*

Street AddressAddress Line 2CityStateZip Code

Insurance Information

Company*

Group #

Policy #*

Phone

Address

Street AddressCityStateZip Code

Policy Holder's Information

Last Name*

First Name*

Middle Name

Employer

Social Security #

Date of Birth*

MM

DD

YYYY

Address

Street AddressCityStateZip Code

Patient's NYS

Medicaid ID #

Sequence #

Agreement

Please check off each of the following items and enter email in the bottom of this sheet:

Agreement*

I authorize the use of this form on all my paper and/or electronic insurance correspondence, billing, and other submissions.
I authorize the release of any information to all my insurance companies, past or present.
I authorize my doctor to act as my agent in helping me obtain payment from my insurance companies.
I authorize payment direct to my doctor and Southern Tier Pediatrics Practice, P.C.
I permit a copy of this authorization to be used in place of the original.
I understand that I am responsible for maintaining this account and that I alone am responsible for my child/children’s bill(s). I further understand that by signing this agreement, I am agreeing to have the providers at the private practice of Southern Tier Pediatrics Practice, P.C. treat my child as a “private-pay” patient at every visit. I understand that if, for any reason at all, my insurance carrier does not pay for services rendered, I will be responsible for any and all unpaid portions. If there are any other parties responsible for payment for my child’s healthcare expenses, I understand that I will be responsible to obtain that reimbursement from such parties on my own once I have paid my account with Southern Tier Pediatrics. ***Please note that it is the policy of Southern Tier Pediatrics Practice, P.C. that the parent/guardian who requests treatment for the patient is responsible for all fees for service rendered. Any and all late fees, bank fees, and collection fees are the responsibility of the account holder.***

I have completed this form fully and completely and certify that I am either the parent, legal guardian, patient, or duly authorized general agent of the patient authorized to furnish the information requested. I understand that even though I may have some type of insurance coverage, I am responsible for payment of services.

Name of Responsible Person*

Email of Responsible Person*

Name

This field is for validation purposes and should be left unchanged.

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