Insurance

Insurance

Essex Pediatrics • 89 Main Street, Essex Junction, VT 05452 • (802) 879-6556
Patients

List the name and date of birth for each child in your family who is a patient.
How many children in the family are patients?
Patient 1 Name*
Patient 1 Date of Birth*

MonthDayYear
Date
Patient 2 Name
Patient 2 Date of Birth

MonthDayYear
Date
Patient 3 Name
Patient 3 Date of Birth

MonthDayYear
Date
Patient 4 Name
Patient 4 Date of Birth

MonthDayYear
Date
Patient 5 Name
Patient 5 Date of Birth

MonthDayYear
Date
Patient 6 Name
Patient 6 Date of Birth

MonthDayYear
Date
Primary Insurance
Do you have primary insurance?*

YesNo
Primary Insurance Provider*
ID Number*
Group Number
Subscriber's Name*
Subscriber's Date of Birth*

MonthDayYear
Date
To expedite your benefits confirmation, please upload a copy of the front and back of your insurance card, as well as the front of the subscriber's photo ID. You can use your mobile phone to take these photos.
Front of Insurance Card*

Cancelof
Back of Insurance Card*

Cancelof
Subscriber's Photo ID*

Front of Driver's License or State Photo ID
Cancelof
Secondary Insurance
Do you have secondary insurance?*

YesNo
Secondary Insurance Provider*
ID Number*
Group Number
Copay*
Subscriber's Name*
Subscriber's Date of Birth*

MonthDayYear
Date
Start Date*

MonthDayYear
Date
To expedite your benefits confirmation, please upload a copy of the front and back of your insurance card. You can use your mobile phone to take these photos.
Front of Insurance Card*

Cancelof
Back of Insurance Card*

Cancelof
Subscriber's Photo ID

Front of Driver's License or State Photo ID, if different from Primary Subscriber
Cancelof
Medicaid
Have any of the patients listed above ever been on Medicaid? If so, list their name with the start and end dates:
Insurance Authorization and Assignment (Please Read and Sign)

I attest that the information I have given here is correct and true to the best of my knowledge. I hereby assign benefits to be paid directly to the doctor, and authorize him/her to furnish information regarding my visits to my insurance carrier. I understand that I am responsible for my entire bill unless this form is complete.

During a preventative care visit, if we address additional problems, topics, or concerns, or we address any ongoing chronic medical conditions, we must also document and claim these problems to your insurance company. Depending on your insurance, these additional problems will often be subject to co-pays and deductibles, so you may receive an additional bill for this service. Please see our website for more information.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Insurance

Patients

Primary Insurance

Secondary Insurance

Medicaid

Insurance Authorization and Assignment (Please Read and Sign)