New Patient Information – Dailey Pediatrics and Family Medicine

Date

Patients Legal Name

Date of Birth

SexMaleFemale

Marital Status

Ethnicity

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Home Phone

Cell Phone

Patient's Employer/ Parent Employer

Occupation

Employer Address

Work Phone

Spouse Name (if applicable)

Spouse SSN#

Spouse DOB

**Pediatric Patient only(please list both parents if applicable)**

Parent Name/ legal Guardian

Mothers Name

Mothers Cell Phone

Mother DOB

Mother SSN

Fathers Name

Fathers Cell Phone

Fathers DOB

Fathers SSN

Mothers Employer

Mothers Occupation

Business Phone

Business Email Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Fathers Employer

Fathers Occupation

Business Phone

Business Email Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Emergency Contact #1

Name

Phone

Emergency Contact #2

Name

Phone

Were you referred by someone to us? If so, who?

Person Responsible for Payment

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone

Primary Insurance

Policy Holder Name/ SSN/DOB

Policy Number/ Member ID#

Group #

Secondary Insurance

Policy Holder Name/ SSN/DOB

Policy Number/ Member ID#

Group #

Please Read: All charges are due at the time of service. The patient is responsible for all feed regardless of insurance. It is our policy that progressional services provided in our office be paid at the time of service. There will be a $25 late fee per month on accounts that are 60 days past due. We are in the process of credentialing with multiple private insurance companies and Medicare. As of now, we are a cash only practice. Once we get contracts back and signed with insurance companies, we will begin to file claims with your insurance. You may provide a receipt of services yourself to your insurance company in order for the services to go towards any deductible you may have and for any reimbursement insurance may provide you. If you would like a receipt to submit to your insurance, please let the receptionist or nurse aware prior to leaving the office.

As we obtain contracts with insurance companies, we will let you know at your time of visit.

I hereby authorize Dailey Pediatrics and Family Medicine, P.C. to collect payment at time of service in the form of cash, check, credit or debit. I understand that this is a cash only office at this time, however that can change once insurance contracts are put into pace. At this time, I will be made aware at my office visit and give permission for Dailey Pediatrics and Family Medicine to furnish information to insurance carriers concerning my illness and treatments, and I hereby assign to Dailey Pediatrics and Family Medicine all payments for medical services rendered to myself and dependants. I understand I am responsible for any amount not covered by Insurance.

Signature

Date