WESTFIELD PEDIATRICS

PATIENT REGISTRATION FORM

Today’s Date_______________

PATIENT INFORMATION

Name:  Last________________________First________________Middle___________

Birth date____________________            Sex_______

Address___________________________Town_______________Zip_______

Home Phone (     ) ____________________________

Siblings Names with Birthdates_____________________________________________

PARENT INFORMATION

Mother’s Name_____________________        Father’s Name______________________

Mother’s Date of Birth______________           Father’s Date of Birth_______________

Mother’s SS#_______________________      Father’s SS#________________________

Address___________________________       Address____________________________

Employer___________________________     Employer__________________________

Home Phone (    )__________________          Home Phone (     )___________________

Employer Phone (    )_________________      Employer Phone (    )_______________

Cell Phone (    )____________________        Cell Phone (     )___________________

  INSURANCE INFORMATION

Subscriber’s Name__________________________  SS#______________________

Insurance Company__________________________ Ins Co Phone (    )___________

Insurance Co Address__________________________________________________

Insurance ID#_____________________________ Insurance Group #____________

Insurance Effective Date_____________________

HEALTH SAVINGS ACCOUNT INFORMATION

If you have a health savings account or High Deductible Plan, please provide a copy of your HSA card or a personal credit card that we may keep on file. By signing below, you agree to have your card billed for any non-covered services.

HSA Plan Name_____________________

Card # ____________________________

Name on Card___________________________

Effective Date ___________________

Expiration Date ___________________

Today’s Date_____________                  Signature__________________________

I authorize the release to any referring physician or appropriate insurance company any medical information related to my child’s examination and treatment.  I understand that I am financially responsible for any co-pay, deductible, co-insurance and non-covered expenses.