Face Sheet - Pediatric Medical Associates printable pdf download

PEDIATRIC MEDICAL

[ ] I

[ ] S [ ] WS

ASSOCIATES, P.C.

[ ] UPDATE

4824 E. Baseline Road

Building 3, Suite 125

Mesa, AZ 85206

Date:

____________________

Chart

: __________________

FATHER’S Last Name: ______________________________First _______________________Init____ Home Phone ___________________

Street Address_______________________________________________________________________Work Phone ____________________

City ______________________State______ Zip__________ Birth date _________________________ Soc Sec #______________________

Employer ________________________________________ Occupation ________________________ Yrs. Employed __________________

Cell Phone _____________________

MOTHER’S Last Name: ______________________________First _______________________Init____ Home Phone ___________________

Street Address_______________________________________________________________________Work Phone ____________________

City ______________________State______ Zip_________ Birth date __________________________ Soc Sec # _____________________

Employer ________________________________________Occupation _________________________Yrs. Employed _________________

Cell Phone ____________________

1) [ ] STANDARD INSURANCE INFORMATION:

NAME of POLICY HOLDER: ________________________________________ Effective Date of Coverage________________________

NAME OF INSURANCE COMPANY: ________________________________________________________________________________

Claims Mailing Address: ________________________________________ City ____________________State/Zip ___________________

INSURED’S ID # _________________________GROUP # _________________ DEDUCTIBLE AMT _____________ COPAY _________

2) [ ] AHCCCS PLAN: Circle One –

APIPA

Mercy Care

Care First

Insert AHCCCS ID# for each child below

3) [ ] NO INSURANCE

ALL CHILDREN’S NAMES / DATES OF BIRTH

STANDARD INS PLAN NAME / ID#

AHCCCS INS PLAN NAME / ID#

____________________________________________

________________________________

______________________________

____________________________________________

________________________________

______________________________

____________________________________________

________________________________

______________________________

____________________________________________

________________________________

______________________________

____________________________________________

________________________________

______________________________

NEAREST RELATIVE: Name ______________________________Relation ___________________ Phone ______________________

Address _______________________________________________________________________________

_______________________________________________________________________________

AUTHORIZATION FOR VERIFICATION OF INFORMATION: I certify that to the best of my knowledge the statements contained herein are

true. I authorize PEDIATRIC MEDICAL ASSOCIATES and/or its assignee to verify statements made herein.

RELEASE OF MEDICAL INFORMATION: I authorize the release of any medical information necessary to process claims for insurance

reimbursement or payment. I further authorize payment to PEDIATRIC MEDICAL ASSOCIATES of any medical benefits resulting from

medical or surgical services rendered by PEDIATRIC MEDICAL ASSOCIATES.

FINANCIAL RESPONSIBILITY: I agree to be responsible for all claims and charges incurred by any of the above named children. I

understand that I will be expected to pay for services at the time of each visit, that are required. I further agree to pay all collective costs,

responsible attorney fees, and other costs that may be incurred to enforce collection of any amounts outstanding.

FOR EMERGENCY CARE: I authorize the performance of any necessary medical and surgical treatment of my children in case of illness or

accident when neither parent (nor guardian) can be located. The medical and surgical services required may be performed by the physicians

of PEDIATRIC MEDICAL ASSOCIATES or a licensed physician of their choice, at the medical facility, office, emergency room or hospital of

their choice.

SIGNATURE

________________________________________________________ DATE ___________________________________

Parent/Guardian

Face Sheet - Pediatric Medical Associates

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