Fillable Pediatric Endocrine Associates Patient Information Sheet printable pdf download

PEA Demographics 2014

Pediatric Endocrine Associates

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Patient Name:_____________________________________________ Check one: Male

Female

Date of Birth:_________________________________________! S ocial Security:___________________

Address:____________________________________________!Apt #:___________________________

City:__________________________________State:________________ Zip:______________________

Primary Phone:_____________________________Secondary Phone:___________________________

Parent/Guardian Email:________________________________________________________________

Policy Holders Information (If patient is a minor, please enter parents information)

Name:_______________________________________Social Security:___________________________

Date of Birth:_______________________________Relationship to patient:________________________

Insurance Information (May provide copy of insurance card)

Primary Insurance:________________________________ !

Member #:_____________________

Group #:_______________________

Secondary Insurance:______________________________!

Member #:______________________

Please note: we will bill secondary insurance ONCE as a courtesy. Payment is your responsibility.

Primary Care Provider:

PCP name:_________________________ Phone:________________________Fax:________________

Preferred Pharmacy:_______________________ Phone:______________________Street:_________

I understand that I am responsible for providing the ofﬁce with the correct information. I agree that the all

the information provided above is correct.

By signing my name, I authorize the medical information to be released to my insurance for billing

purposes and for medical care of the patient. I also authorize payment of medical beneﬁts of the above

patient to Dr. Lin, Dr. DeClue, Dr. Lenz and Dr. Dougan for services received.

By signing my name, I take legal responsibility of providing correct insurance information to Dr. Lin, Dr.

DeClue, Dr. Lenz and Dr. Dougan for the service delivered. Any parent or legal guardian (regardless of

marital status) who brings a minor in for treatment is, and hereby agrees to be responsible for paying the

minors account in full. If the information provided is incorrect or incomplete, I will be responsible for

covering the charges on the date the services were rendered. If the patient account is sent to collections,

the patient(s) will also be discharged from this practice.

Signature:___________________________________________ Date:___________________________

Print Name:________________________________________Relationship to patient:______________

Please note that those patients who DO NOT CALL within the allowed time WILL BE CHARGED A $25 FEE. This is

a NON-COVERED service and as such is not payable by insurance. Thank you for understanding this matter.

Signature:____________________________________________Date:__________________________

____________________________FUTURE APPOINTMENTS ONLY____________________________

I agree that the above information (insurance, address, phone and PCP) is still correct and complete.

1. Date:_____________________Signature:______________________My insurance is the same (Y / N)

Is there secondary insurance (Y / N)

2. Date:_____________________Signature:______________________My insurance is the same (Y / N)

Is there secondary insurance (Y / N)

Pediatric Endocrine Associates Patient Information Sheet

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