Pediatric Patient Registration

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Child's Date Of Birth
Child's Sex
Primary Insured Or Financially Responsible Person's Date Of Birth
Primary Insured Or Financially Responsible Person's Sex
Primary Health Plan Name
Relationship Of Child To The Primary Insured/Responsible Party
Is There A Secondary Health Plan?

Authorizations and Notices

I authorize BayCare Medical Group to treat my child for pediatric care.
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
Required HIPPA Privacy Practices Notice:
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.
Payments Required By BayCare Medical Group and Dr. Fox. The charge for an office visit is $250 payable at the time of service. 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.
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