BayCare Medical Group of California

General Peds Clinic
COVID Clinics
Autoimmunity Clinics
Contact Us
Campbell Location (Santa Clara County)
Santa Cruz Location (Santa Cruz County)

BayCare Medical Group of California

Autism Clinic
Campbell Location (Santa Clara County)
Contact Us
New Adult Patient Registration
New General Pediatric Patient History- Ages Newborn To Five Years
New General Pediatric Patient History- Ages Six To Seventeen Years
New Post-COVID Vax Injury Patient History
Other Autoimmunity Disorders
Parkinson’s Clinic
Pediatric Patient Registration
Santa Cruz Location (Santa Cruz County)
Type 1 Diabetes Clinic

Pediatric Patient Registration

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Child's First Name *

Child's Last Name *

Child's Street Address *

Child's City *

Child's State *

Child's Zip Code *

Child's Date Of Birth *

Child's Sex *

Female
Male

Parent's First Name *

Parent's Last Name (Only If Different Than Child's Last Name)

Parent's Street Address (Only If Different Than Child's Street Address)

Parent's City (Only If Different Than Child's City)

Parent's State (Only If Different Than Child's State)

Parent's Zip Code (Only If Different Than Child's Zip Code)

Parent's Phone *

Parent's Email *

Primary Insured Or Financially Responsible Person's First Name *

Primary Insured Or Financially Responsible Person's Last Name (Only If Different Than Child's Last Name)

Primary Insured Or Financially Responsible Person's Street Address (Only If Different Than Child's Street Address)

Primary Insured Or Financially Responsible Person's City (Only If Different Than Child's City)

Primary Insured Or Financially Responsible Person's State (Only If Different Than Child's State)

Primary Insured Or Financially Responsible Person's Zip Code (Only If Different Than Child'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

If "Other" Health Insurance Plan, Enter The Name Of It Here

Primary Insured's Health Plan Policy Number

Relationship Of Child To The Primary Insured/Responsible Party

Child
Self
Other, Explain Below In Comments Field

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

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 *

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