Child Registration Form

Please fill out this form for your child before their first appointment

Patient Information

Patient First Name

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Patient Middle Initial

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Patient Last Name

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Date of Birth

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Patient Gender

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Social Security #

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Language

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Race

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Hispanic or Non-Hispanic

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Home Address

Street Address

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City

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State

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Zip Code

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Pharmacy (Name & Address)

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Primary Care Doctor

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Primary Care Doctor Address

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Primary Care Doctor Phone #

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Referring Care Doctor (If Different From Primary)

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Referring Care Doctor Address

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Referring Care Doctor Phone #

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Guardian Information

Contact Information

Parent/Guardian Phone #

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Alternate Parent/Guardian Phone #

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Parent/Guardian Email

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Preferred Contact

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Parent/Guardian 1

Parent/Guardian First Name

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Parent/Guardian Last Name

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Parent/Guardian Date of Birth

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Parent/Guardian Social Security #

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Parent/Guardian 2

Parent/Guardian First Name

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Parent/Guardian Last Name

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Parent/Guardian Date of Birth

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Parent/Guardian Social Security #

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Insurance Information

Primary Insurance

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Secondary Insurance

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Vision Insurance (For Optical Servies Only)

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Payment For Services

PATIENT RESPONSIBILITY

You will be responsible for co-pays and any balances not covered or paid by insurance. Routine eye care is not covered by many insurances. Therefore, if there is not a medical diagnosis, we ask that you pay at the time of service. We will still bill your insurance for you and if they do pay, you will receive a refund. If you do not have insurance, you are responsible for the full amount of fee at the time of service. We do accept credit/debit/HSA cards/checks and cash.

The parent/guardian who brings the child to the office is ultimately responsible for payment of the fees regardless of who the insured party is. If a person other than a parent brings a child, they are responsible for payment of the fees at the time of service unless they have all your insurance information including a copy of the insurance card that includes a billing address.

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

I authorize the release of any medical information acquired or required during the examination and ongoing treatment by Pediatric Ophthalmology of Erie. I understand that Pediatric Ophthalmology of Erie will correspond with and may otherwise convey information regarding patients’ medical status to the referring physician, the primary care physician and insurance companies requested.

AUTHORIZATION FOR ASSIGNMENT OF BENEFITS

I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicare, private insurance, and other health plans to Pediatric Ophthalmology of Erie. I authorize the release of any medical and/or other information necessary to process the claim.

NOTICE OF IMPAIRED VISION (For Adults)

I understand that the examination I received may impair my vision and/or operation of mechanical equipment. I also realize that I may be unable to react with normal speed and accuracy. I have been advised that a driver should accompany me. I will plan for my own transportation.

I agree to Pediatric of Ophthalmology of Erie’s Notice of Payment Services Policy.

Authorization To Release Health Information To Family/Friends (that are not legal parents)

AUTHORIZATION TO RELEASE HEALTH INFORMATION TO FAMILY/FRIENDS (that are not legal parents)

Allowed info and/or to bring to appointments

To make it easier to discuss medical care about you with those that help you with care, we ask that you complete this form.
Example of who needs permission for us to talk to would be grandparents, partners, aunts/uncles, siblings, friends, etc.

I authorize Pediatric of Ophthalmology of Erie to share medical information with friends & family

I have received Pediatric of Ophthalmology of Erie’s Notice of Privacy Practices and I have been provided the opportunity to review it. (Located on the website)

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Date

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