Pediatric Registration Form

  • Child’s Information

  • Mother/Guardian

  • Father/Guardian

  • Emergency Contact Information (A local person other than Parents or Guarantor)

  • HIPAA Disclosure (People other than parents/guardians)

  • Insurance Information

    (Please provide all the insurances for the child. Not providing all the insurance information will result in the patient being discharged from the practice)
  • Who is authorized to bring the child(ren) for a visit and make medical decisions on their behalf?

  • CONSENT FOR EXAMINATION, MEDICAL TREATMENT AND CONDITIONS OF EXAMINATION

  • INFORMATION CONCERNING FILING A CLAIM WITH YOUR INSURANCE COMPANY

  • AUTHORIZATION TO FILE INSURANCE CLAIMS, TO RELEASE MEDICAL INFORMATION AND ASSIGNMENT OF BENEFITS

  • AGREEMENT AS TO CO-PAYMENTS, NON-COVERED OR NON-PAID SERVICES AND GUARANTEE OF PAYMENT

  • Authorization for Request of Medical Records

  • I hereby authorize the release of information from the medical record of:

  • Please Release Information To:

  • Preferred Medical Group: Centralized Fax: (334) 664-0466

  • Informed Consent for Release of Confidential Information.

  • I understand that I may revoke this consent in writing at any time except to the extent action has been taken. I understand that this consent will expire 90 days after the date of my signature unless otherwise specified. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by Federal Privacy Regulations.

  • This field is for validation purposes and should be left unchanged.
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