Father Guardian

First Name

Middle Name

Last Name

Date of Birth

SSN

Cell Phone

Ethnicity/Race

Employer

Employer Name

Employer Phone

Employer Address

Employer City

Employer State

Employer Zip

Mother Guardian

First Name

Middle Name

Last Name

Date of Birth

SSN

Cell Phone

Ethnicity/Race

Employer

Employer Name

Employer Phone

Employer Address

Employer City

Employer State

Employer Zip

Billing Address

Physical Address

Emergency Contact

Patient Information

Insurance Information

Primary Insurance

Copay Not Required

Insurance Company Name

Address

City

State

Zip

Subscriber Name

Subscriber Date of Birth

Subscriber SSN

Insurance Effective Date

Subscriber Insurance Id

Subscriber Group Number

Secondary Insurance

Copay Not Required

Insurance Company Name

Address

City

State

Zip

Subscriber Name

Subscriber Date of Birth

Subscriber SSN

Insurance Effective Date

Subscriber Insurance Id

Subscriber Group Number

Third Insurance

Copay Not Required

Insurance Company Name

Address

City

State

Zip

Subscriber Name

Subscriber Date of Birth

Subscriber SSN

Insurance Effective Date

Subscriber Insurance Id

Subscriber Group Number

I authorize assignment of benefits to Idaho Falls Pediatrics and authorize previously named clinic to release any information requested to receive payment.

On occasion, you may wish to have your Child brought to the Clinic by someone other than a parent. Please list the names of those individuals who have your permission to bring your child in for assessment and/or treatment. A day care worker of grandparent is an example of someone you would allow to bring your child in. If you do not want anyone to be authorized, please write NONE on the name line and sign at the bottom.

The Child listed in this packet may be brought in for assessment and treatment by the following individuals:

Update Patient Info

Employer

Employer

Billing Address

Physical Address

Emergency Contact

Patient Information

Insurance Information

Primary Insurance

Secondary Insurance

Third Insurance