Fayetteville Children'S Clinic Patient Information Form printable pdf download

Fayetteville Children’s Clinic

Chart #_____________

P. O. Box 53127

Primary Doctor: ______________

Fayetteville, NC 28305

Updated by: _________________

Please note that insurance cannot be filed until ALL information is completed and a copy of your card is on file. Due to new guidelines set

by the insurance companies, you may be required to present your insurance card at each visit. Please bring your most recent insurance

card with you. Well child visits will be rescheduled for a more convenient time if the copay is not paid.

Patient information:

Name: First _____________________Middle____________Last____________________Sex: M F Date of Birth: _____________

County: ______________________ Social Security #:___________________

Home Phone: ____________

Street Address: _________________________________ City: ________________State:__________ Zip Code: _______

Please circle if your child is covered by one of these policies:

NC Health Choice Medicaid

BCBS Blue Advantage

If you circled Blue Advantage, is the child the only one on this policy? Yes No

Mother/Guarantor Information:

Name: ________________________________ Date of Birth: ___________________ Social Security# ________________

Relationship to child: Mother StepParent Grandparent Legal Guardian

Home address: _____________________________________________________Mom’s Maiden Name__________________________

Work Phone: ______________Cell Phone: _____________ Home Phone: ______________Occupation: ________________

Internet Address:_____________________________________Employer:__________________________________

Do you have insurance with this company? Yes No

If yes, is the above named CHILD covered by this policy? Yes No If yes, a copy of the insurance card is REQUIRED.

Name of Insurance: _____________________________________________Effective Date:_______________________________

Father/Guarantor Information:

Name: _________________________________ Date of Birth: _________________ Social Security _______________________

Relationship to child: Father StepParent Grandparent Legal Guardian

Home address: ____________________________________________________

Work Phone: _______________Cell Phone: _______________ Home Phone: ______________Occupation: _______________________

Internet Address: ________________________________ Employer:______________________________

Do you have insurance with this company? Yes No

If yes, is the above named CHILD covered by this policy? Yes No If yes, a copy of the insurance card is REQUIRED.

Name of Insurance: _____________________________________________________Effective Date: ______________

If either parent/guardian is active duty military, please provide the following information:

Company Commander: ____________________________________________Unit:____________________________________

Unit Phone # _____________________________________________________

I hereby authorize my insurance benefits to be paid directly to the above signed physician(s), realizing I am responsible to pay

noncovered services and I hereby authorize the release of pertinent medical information to insurance carriers. This

authorization shall be valid unless rescinded in writing by one of a later date.

Parent/legal guardian signature:_________________________________________________________________

Fayetteville Children'S Clinic Patient Information Form