Medical Information Release And Assignment Of Benefits Sheet
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1UPDATE INFORMATION
PATIENT'S INFORMATION
M F
DOB
SS#
FULL NAME
M F
DOB
SS#
FULL NAME
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
HOME PHONE NO.:
PREFERRED PHARMACY
RACE:
PRIMARY LANGUAGE SPOKEN:
CHILD'S ETHNICITY: ___HISPANIC ___NON HISPANIC
FAMILY EMAIL ADDRESS:
PARENT'S INFORMATION
SS#.:
MOTHER'S NAME:
DOB:
/
/
DO YOU WISH TO RECEIVE
EMPLOYER:
WORK NO:
TEXT MESSAGE REMINDERS? _______
CELL PHONE NUMBER:
WHO IS YOUR CELL PHONE WITH?
SS#.:
FATHER'S NAME:
DOB:
/
/
DO YOU WISH TO RECEIVE
EMPLOYER:
WORK NO:
TEXT MESSAGE REMINDERS? _______
CELL PHONE NUMBER:
WHO IS YOUR CELL PHONE WITH?
OTHER
CHILD LIVES WITH (CIRCLE ONE)
MOTHER
FATHER
BOTH
SS#.:
GUARDIAN'S NAME:
DOB:
/
/
EMPLOYER:
WORK NO:
CELL PHONE NUMBER:
EMERGENCY CONTACT (OTHER THAN PARENTS):
ADDRESS:
PHONE NO.
BILLING AND INSURANCE INFORMATION
ALL CO-PAYS AND PAST DUE BALANCES ARE DUE AT THE TIME OF SERVICE UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE.
PRIMARY INSURANCE (WE WILL NEED A COPY OF THE CARD)
NAME OF INS. CO.: ________________________________________________________________________________________________
CONTRACT #:____________________________________________GROUP #________________________________
POLICY HOLDERS NAME _______________________________
DOB:__________________________________
POLICY HOLDERS NAME: EMPLOYER:____________________________
RELATIONSHIP TO PT: _____________________________________
SECONDARY INSURANCE (WE WILL NEED A COPY OF THE CARD)
NAME OF INS. CO.: ________________________________________________________________________________________________
CONTRACT #:____________________________________________GROUP #________________________________
POLICY HOLDERS NAME _______________________________
DOB:__________________________________
RELATIONSHIP TO PT: _____________________________________
POLICY HOLDERS NAME: EMPLOYER:____________________________
By listing numbers on this form, I give Pediatric Associates of Auburn, and/or our agents permission to contact you by telephone at
any telephone number associated with your account, including wireless telephone number, which could result in charges to you. We may
also contact you by sending text messages or emails, using any email address you provide to use. Methods of contact may include using
prerecorded/artificial voice message and/or use of automatic dialing device, as applicable.
MEDICAL INFORMATION RELEASE AND ASSIGNMENT OF BENEFITS
I UNDERSTAND THAT PAYMENT OF ALL MEDICAL CARE IS DUE AT THE TIME OF SERVICE. THE PARENT AND/OR LEGAL GUARDIAN WHO SIGNS THIS
FORM IS RESPONSIBLE FOR ANY AND ALL CO PAYS, DEDUCTIBLES, CO-INSURANCE, AND/OR UNPAID BALANCES NOT COVERED BY INSURANCE,
REGARDLESS OF MARTIAL STATUS. I, THE UNDERSIGNED, ACCEPT THE FEE CHARGED AS A LEGAL AND LAWFUL DEBT AND AGREE TO PAY SAID FEE,
INCLUDING ANY/ALL COLLECTION AGENCY FEES, (33.33%), ATTORNEY FEES AND OR COURT COSTS, IF SUCH BE NECESSARY. I HEREBY GRANT
PERMISSION TO RICHARD M. FREEMAN MD PC (PEDIATRIC ASSOCIATES OF AUBURN) TO RELEASE AND OBTAIN ANY PERTINENT INFORMATION
NEEDED FOR TREATMENT AND/OR PAYMENT; I ALSO AUTHORIZE PAYMENT DIRECTLY TO RICHARD M. FREEMAN MD PC (PEDIATRIC ASSOCIATES OF
AUBURN). A PHOTOCOPY OF THIS AUTHORIZATION SHALL BE CONSIDERED AS EFFECTIVE AND VALID AS THE ORIGINAL.
Date: _________________________
Signature of Parent or Guardian___________________________________________________________
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