Orange Pediatrics
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7ACCOUNT NUMBER
ORANGE PEDIATRICS
251 Maitland Ave Ste 104 Altamonte Springs FL 32701
PATIENT INFORMATION
PATIENT'S NAME-LAST
FIRST
MIDDLE
SEX
DATE OF BIRTH
PATIENT SOC. SEC. NO
CHILD LIVES WITH:
PERSON TO BILL:
SIBLING'S NAME-LAST
FIRST
MIDDLE
SEX
DATE OF BIRTH
SIBLING'S SOC. SEC. NO.
CHILD LIVES WITH:
FAMILY INFORMATION
FATHER'S NAME-LAST
FIRST
MIDDLE
EMPLOYER
HOME ADDRESS
CITY
STATE
ZIP CODE
HOME PHONE
WORK PHONE
DATE OF BIRTH
SOC. SEC. #
MOTHER'S NAME-LAST
FIRST
MIDDLE
EMPLOYER
HOME ADDRESS
CITY
STATE
ZIP CODE
HOME PHONE
WORK PHONE
DATE OF BIRTH
SOC. SEC. #
How did you find us
Email:
?
INSURANCE INFORMATION
INSURANCE COMPANY NAME:
SUBSCRIBER'S NAME
POLICY NUMBER
GROUP NUMBER
OTHER INFORMATION
NAME and PHONE NUMBER OF RELATIVE,FRIEND OR NEIGHBOR WHO CAN BE REACHED IN CASE OF EMERGENCY:
METHOD OF PAYMENT:
YOUR DRIVER'S LICENSE NO.
COPY OF DRIVER'S
LICENSE & INSURANCE
CARD IS REQUIRED.
NAME OF PERSON BRINGING IN CHILD:
RELATIONSHIP:
All professional services rendered are charged to the patient. The patient is responsible for all fees, regardless of insurance coverage. It is customary to
pay for services when rendered unless other arrangements have been made in advance. Parent or the legal guardian will be responsible for all services
not covered by their insurance. Any services not paid by parent or the responsible party will be forwarded to collections and will include collection fee.
INSURANCE AUTHORIZATION AND ASSIGNMENT
I hereby authorize Devyani Belsare, M.D. to furnish information to insurance carriers concerning my child's illness and treatments and I hereby assign to
the physician all payments for any amount not covered by my insurance.
Signature of parent / legal guardian
Date
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Parent category: Medical