New Adult Patient Registration New Adult Patient Registration New Adult Patient Registration New Adult Patient Registration Patient's First Name * Patient's Last Name * Patient's Street Address * Patient's City * Patient's State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Patients's Zip Code * Patient's Birthdate * Patient's Sex * Female Male Patient's Phone * Patient's Email * Name Of Emergency Contact Person Emergency Contact Phone Number Primary Insured Or Financially Responsible Person First Name * Primary Insured Or Financially Responsible Person Last Name * Primary Insured Or Financially Responsible Person Street Address * Primary Insured Or Financially Responsible Person City * Primary Insured Or Financially Responsible Person State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Primary Insured Or Financially Responsible Person Zip Code * Primary Insured Or Responsible Person Date Of Birth * Primary Insured Or Responsible Person Sex * Female Male Primary Health Plan Name * Aetna Blue Cross Blue Shield Cigna Medicare United Healthcare Other - Provide Name Below None Other Primary Health Plan Name * Primary Insured's Health Plan Policy Number * Relationship Of Patient To The Primary Insured/Responsible Party * Self Spouse Child Other, Explain Below In The Comments Section Is There A Secondary Health Plan? * No Yes 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. 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 Captcha If you are human, leave this field blank. Submit
