sbspediatrics.com - Registration & HIPAA Form (English)

Patient Registration
Patient Information
Chart/MR#
Patient Name
SSN
Sex

MaleFemale
Date

MonthDayYear
Date
Race/Ethnicity
Mother’s Name
DOB

MonthDayYear
Date
SSN
Home Phone
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone

Area CodePhone Number
Work Phone
Please enter a valid phone number.
Employer/Occupation
Father’s Name
DOB

MonthDayYear
Date
SSN
Home Phone
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone

Area CodePhone Number
Work Phone
Please enter a valid phone number.
Employer/Occupation
Email Address
MotherFatherOther

Other Children in Family:

	Name	Sex	DOB	SSN
1
2
3
4

Children live with:

MotherFatherOther
Emergency Contact Person
Relationship
Phone Number
Please enter a valid phone number.
Party Responsible for Payment of Medical Services:

FatherMotherBothOther
Who referred you to our office?
Insurance Information
Primary
Claims Address
Policy #
Group #
Co-payment $
Secondary
Claims Address
Policy #
Group #
Co-payment $
Name of Insured
DOB

MonthDayYear
Date
Relationship
Medicaid/Other
Current Card #
Physician (PCP) name listed on Card
Phone Number
Please enter a valid phone number.
Authorization of Treatment and Assignment of Benefits

I authorize Step By Step Pediatrics, PC to treat my child. I further authorize the release of medical information necessary for the completion of insurance forms. I authorize payment directly to Step By Step Pediatrics, PC for all medical benefits otherwise payable to me under the terms of my insurance. I understand that I am financially responsible for all co-payments and any charges not payable by my insurance. A photocopy of this authorization shall be considered as effective and valid as the original. If my unpaid balance is turned over to an outside collection agency, I understand that I am responsible for any and all applicable collection fees.
I understand that if my child’s physician, or any person employed by or under the direction and control of my child’s physician(s), is directly exposed to my child’s body fluids in any manner which may, according to the then current guidelines for the Center for Disease Control, transmit the human immunodeficiency virus (HIV) or hepatitis B or C viruses, that I am deemed by law to have consented to testing for infection with HIV or hepatitis B or C viruses. I further understand that by law I will have deemed to have consented to the release of these test results to the person who is exposed to my child’s body fluids.
Parent/Guardian’s Signature

Clear
Relationship
Date

MonthDayYear
Date
Witness Signature

Clear
Date

MonthDayYear
Date

HIPAA Authorization Statement

Complete and sign the section below regarding confidential release of information.
Please complete the following so that we may contact you properly and securely.

Please list the family members or other persons, if any, whom we may inform about your child’s general medical condition and diagnoses (including treatment, payment, and health care options).
Name
Phone Number
Please enter a valid phone number.
Name
Phone Number
Please enter a valid phone number.
Please list the family members or other persons, if any, who may, in your absence, accompany your child for medical care or immunizations
Name
Phone Number
Please enter a valid phone number.
Name
Phone Number
Please enter a valid phone number.
Please list the family members or significant others, if any, whom we may inform about your child’s medical condition ONLY IN AN EMERGENCY
Name
Phone Number
Please enter a valid phone number.
Name
Phone Number
Please enter a valid phone number.
Please print the address of where you would like your billing statements and/or correspondence from our office to be sent if other than your home
Please print the telephone number where you want to receive calls about your appointments, lab and X-ray results, or other health care information if other than your home telephone number.
(Please be aware that a cell phone is not a secure and private means of communication.)
Can confidential messages (i.e., appointment reminders) be left on your telephone answering machine or voicemail

YesNo
No Please print your email address for office communication purposes only (we will not release this information to any outside party)
example@example.com
Please list your preferred method of contact:

PhoneEmailMail
Patient Name
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Note:
Should be Empty:

Patient Registration

Insurance Information