Minor Patient Registration Information Form printable pdf download

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Fax (501) 778-1013

Phone (501) 778-0934

Preferred Physician:

 Cooper

 Watson  Cathcart

 Albey

Minor Patient Registration Information

 Wright

 Barker

 Dixon

 Morgan

Patient’s Personal Information

Name: _________________________________________

SS#: ____ - ____ -_____ Date of Birth: __ / __ / ____

Last

First

Sex: M / F

Primary phone #: (_____)________________

Alternate phone #: (_____)___________________

Primary E-mail:_____________________________________________________

Child’s Primary Address: ___________________________________ City: _____________ State:_______ Zip:_________

Mother or Parent One Name:_______________________ Cell Phone #: (_____)___________ SS#:_____-_____-______

Father or Parent Two Name:________________________ Cell Phone #: (_____)___________ SS#:_____-_____-______

 English

 White

 African American

 Asian

 Other

 Not Hispanic/ Latino

Race:

Ethnic Group:

Primary Language:

 Spanish

 Native American Indian/Alaskan  Decline to answer

 Hispanic/Latino

 Other

 Native Hawaiian/Other Pacific Islander

 Decline to answer

Emergency Contact—

Preferred Pharmacy

Please list someone that would not be with child

Name:___________________________ Relationship:______________________

Name: ____________________

Best Phone: (___)_______________ Alternate Phone: (___)_________________

Phone #:___________________

Guarantor Information

Relationship to patient:  Father

 Mother

 Other___________

(Person responsible for child’s bills)

Name: _________________________________________

SS#: ____ - ____ -_____ DL#: ________________

Last

First

Date of Birth: ___ / ___ / ____ Main phone#: (___)_______________ Alternate phone: (___)_____________

Address: ______________________________ Apt#: ______ City: _____________ State:______ Zip:_________

Employer:_________________________ Work phone: (___)_______________ Occupation:__________________

Patient’s Insurance Information

Primary Insurance Company: __________________________ ID#: _____________________ Group#: ________________

Subscriber Name: _________________________ Date of Birth: ___ / ___ / ____ Main phone#: (___)_________

 Self  Father  Mother  Other________ Copay: $________

Subscriber’s relationship to patient:

Secondary Insurance Company: ________________________ ID#: _____________________ Group#: _________________

Subscriber Name: _________________________ Date of Birth: ___ / ___ / ____ Main phone#: (___)_________

 Self  Father  Mother  Other________ Copay: $________

Subscriber’s relationship to patient:

I request that payment of authorized insurance benefits be made on my child’s behalf to the provider indicated above for services furnished to my child. I

authorize any holder of medical information about my dependent to release to the insurance company any information needed to determine these

benefits or the benefits payable for related services. A photocopy of this assignment is to be considered as the original. I understand that I am financially

responsible for all charges whether or not covered by said insurance. This assignment will remain in effect until revoked by me in writing. I further agree to

pay the cost of collection, court costs, and other reasonable fees should they be required in the event of my non-payment. (The parent signing this form

will be financially responsible for the child. Any legal agreement, or other disagreement, between parents in a divorce situation must be dealt with

between those parties and does not involve Family Practice Associates.)

_________________________________________

_____________________

Parent/Legal Guardian Signature

Date