New Pediatric Patient Registration New Pediatric Patient Registration New Pediatric Patient Registration Child's First Name * Child's Last Name * Child's Street Address * Child's City * Child's State * AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Child's Zip Code * Child's Date Of Birth * Child's Sex * Female Male Parent Or Other Caretaker's First Name * Parent Or Other Caretaker's Last Name * Parent Or Other Caretaker's Street Address * Parent Or Other Caretaker's City * Parent Or Other Caretaker's State * AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Parent Or Other Caretaker's Zip Code Parent Or Other Caretaker's Phone * Parent Or Other Caretaker's Email * Parent Or Other Caretaker's Relationship To Child * Mother Father Step-Mother Step-Father Grandparent Other Related Family Member Appointed Guardian Other Primary Insured Or Financially Responsible Person's First Name Primary Insured Or Financially Responsible Person's Last Name Primary Insured Or Financially Responsible Person's Street Address Primary Insured Or Financially Responsible Person's City Primary Insured Or Financially Responsible Person's State * AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Primary Insured Or Financially Responsible Person's Zip Code Primary Insured Or Financially Responsible Person's Date Of Birth * Primary Insured Or Financially Responsible Person's Sex Female Male Primary Health Plan Name * Aetna Blue Cross Blue Shield CHAMPUS/VA Cigna Tricare United Healthcare Other - Provide Name Below None Other Primary Health Plan Name Primary Insured's Health Plan Policy Number Relationship Of Child To The Primary Insured/Responsible Party Child Self Other, Explain Below In The Comments Section Is There A Secondary Health Plan? No Yes Secondary Insured Person's First Name Secondary Insured Person's Last Name Secondary Health Plan Name Secondary Health Plan Policy Number Are There Any Other Comments That You Wish To Make? Authorizations and Notices I authorize BayCare Medical Group to treat my child for pediatric care Yes Communication Authorization: I authorize BayCare Medical Group And Its Doctors To Communicate With Me Regarding The Child's Care By Telephone, Text Message, or Email Yes Required HIPPA Privacy Practices Notice: Click here to see our HIPPA Practices Notice Click here to skip our HIPPA Practices Notice HIPPA Notice-BayCare, 4-18-2024 Required Medical Board of California Notice To Consumers: Richard B. Fox, M.D.,J.D., CA Medical License #G67169 provides this NOTICE TO CONSUMERS: Medical doctors are licensed and regulated by the Medical Board of California (800) 633-2322, www.mbc.ca.gov. Click "yes" to acknowledge receipt of this legally required notice. * Yes Payments Required By BayCare Medical Group and Dr. Fox. The charge for an office visit is $250 payable at the time of service by cash, check, or Zelle. Phone calls are no charge up to two per office visit. As a courtesy, we will provide you with a filled out insurance claim form that you can submit to your insurance plan for reimbursement for your office visit. I agree to the financial terms above I decline the financial terms above Name Of Person Submitting This Information: * Date Submitted File Name END Captcha If you are human, leave this field blank. Submit
