• Family Account Registration

    This form collects information to create your family's account with Small Town Pediatrics. We need this information to schedule an appointment for your child or children. This information will also help us to set up your family's account and bill your insurance company directly for our services. If you already have an established account and only need to add an additional child or new baby, please send a patient portal message or call/text us at (503) 400-3852.
  • Prior to registering your child or children with us, please review our financial and vaccine policies.  These are found on our Small Town Pediatrics webpage.

     

    if you do not wish to comply wih Small Town Pediatrics minimum vaccination requirements, we may not be your best fit for your family's pediatric care.  Please consider seeking care with another medical provider.  Our policy exists to protect our patient population, including pregnant moms.  Many babies under our care are not yet eligible to be protected by vaccination and some children have serious medical conditions which increase their risks of harm from contracting a vaccine preventable disease.

  • Please provide an emergency contact.  We may need to we need to urgently contact you with information about your child. If we are unable to reach a parent or guardian, who should we contact?

  • Information on Your Family's Primary Insurance Policy

    Most families have only one health insurance plan for all children in the family. If you have children covered by an additional "primary" insurance plan we collect that information on the following page. This portion of the form requests information for the main (or only) health insurance plan for your child or children.
  • Small Town Pediatrics needs to know some information about the "guarantor" or "subscriber" to the health insurance policy providing coverage for the child or children being registered.

    The "guarantor" is the adult who provides the health insurance and/or pays for the child's medical care costs.  This may be the same as the primary or "custodial" parent or another person...  For Medicaid plans and some others the guarantor is the child.

    If one or more children do not have health insurance, enter the name of the person responsible for paying for the office visit bills as the "guarantor"

  • Information From Patient Insurance Card

  • Insurance Info Pro Tip:  Send us a photo of the front and back of the "primary" insurance cards for your child or children!

     

    We only need one photo of the back of the card for each plan.  If the guarantor or another an adult has the same information on the back of their card, the child's fronts can be photgraphed or scanned with the parent's card back.

  • Add Insurance Card Images or Documents
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  • Children Covered by This Insurance Plan:

    Respond "yes" when asked if there is an additional child covered by this plan to add up to 5 children covered by this insurance plan. Children covered by a DIFFERENT "primary" insurance plan can be entered on a following page. We will request/confirm any "secondary" insurance or "double coverage" at the time of a scheduled appointment.
  • First Child Information

  • Second Child Information

  • Third Child Information

  • Fourth Child Information

  • Fifth Child Information

  • Second "Primary" Insurance Policy Information

    Use this page to provide information on any second "primary" insurance plan or second "guarnator" for any children who are not on the first "primary" plan from the prior page.
  • The "guarantor" is the adult who is responsible for providing the insurance and or paying for the child's healthcare.  This is the same as the "subscriber" to the health insurance.

  • Information From Patient Insurance Card

  • Insurance Info Pro Tip:  Send us a photo of the front and back of the "primary" insurance cards for your child or children!

     

    We only need one photo of the back of the card for each plan.  If the guarantor or another an adult has the same information on the back of their card, the child's fronts can be photgraphed or scanned with the parent's card back.

  • Add Insurance Card Images or Documents
    Drag and drop files here
    Choose a file
    Cancelof
  • Children Covered by This Insurance Plan:

    Respond "yes" when asked if there is more than one child with this insurance in the family. You can add up to 3 children covered by this "second" insurance plan. We will request/confirm any "secondary" insurance or "double coverage" at the time of a scheduled appointment.
  • Second Insurance Plan

    First Child Information

  • Second Child Information

  • Third Child Information

  • Almost Done!

    The information provided on this secure form will allow Small Town Pediatrics to register your family with us. When your account is set up, we will be able to schedule appointments, and give you access to our Patient Portal
  • By clicking "ENROLL" below, you are requesting Small Town Pediatrics to create a family account for you and your child or children.  To complete this process we may need to contact you by phone, text or email for clarification or additional information.  In some cases we may wait to follow-up until a child has an appointment with us.  

     

    There is no charge to you nor your insurance for setting up this account.  The only purpose is to make it possible to schedule appointments, communicate with you and bill for future medical services. 

     

    When you enroll, you will be directed to another form for medical records transfer.  This form is needed for all children except newborn infants.

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