Primary Insurance Plan

Primary Insurance Plan

Pediatric Development Center of Atlanta, LLC - Online Form
Subscriber Name*

First NameLast Name
Subscriber Date of Birth*

MonthDayYear
Date
Address*

Street Address

CityState

Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Primary Insurance Company Name*
ID Number*
Group Number*
Insurance Company Phone Number*

Area CodePhone Number
Effective Date of Coverage*
Do You Have Secondary Insurance - If Yes Please Complete Secondary Insurance Form*
I authorize our insurance benefits be paid directly to Pediatric Development Center of Atlanta. I also authorize Pediatric Development Center of Atlanta and our insurance company to release any information required to process our claims. I agree to pay for all charges denied by my insurance carrier, including, but not limited to: non-covered services, deductibles, co-pays, services exceeding maximum benefit limits, and for services for which a referral authorization was not properly obtained. I shall promptly notify Pediatric Development Center of Atlanta of any changes in Insurance coverage.
Signature*
Type Full Name*

First NameLast Name
*
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