(Last Name, First Name, Middle Initial): Gender
Mailing Address: City: State
: Zip Code:
Please provide at least two contact phone numbers and indicate which is the best contact number by checking the corresponding box below.
Home Phone: Mobile Phone: Work Phone:
(It is very important that we have multiple phone numbers in order for our medical staff to contact you quickly with lab results & general return phone calls)
Emergency Contact: Relationship to Patient: Phone:
Responsible Party (This person must sign financial policy)
Siblings Who Are Also Seen at Cornerstone Pediatrics (please list all siblings who are also seen by our physicians):
Insurance Information (Primary Coverage):
Do you have additional medical insurance?
(if so, please list below)
Insurance Information (Secondary Coverage):
How Did You Hear About Us?
Please check all that apply:
Online Yellow Pages
New Neighbor Welcome Service or Other New Resident Welcome Service
Assignment & Release:
I give permission for Physicians of Cornerstone Pediatric & Adolescent Medicine, or persons designated by them, to interview, examine and perform necessary laboratory procedures and to provide appropriate treatment to the above named minor. I further give my permission for evaluation and treatment whether the child is accompanied by a parent/legal guardian, other family member, unrelated third party or is unaccompanied.
I, the undersigned, assign directly to Cornerstone Pediatric & Adolescent Medicine, PA all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the use of this signature on all insurance submissions.
I further authorize Cornerstone Pediatric & Adolescent Medicine, PA to forward any information necessary, including, but not limited to medical records, to said insurance company for payment of my insurance claims as well as to other personnel to whom physicians of Cornerstone Pediatric & Adolescent Medicine have referred my child for treatment and to the admitting hospital should my child be admitted for treatment.
PLEASE NOTE: Whoever accompanies the child to each visit is expected to pay the charges due for the service rendered that day, including copayments, coinsurance, deductibles, etc. Divorce has no bearing on the responsibility for medical care as it affects third parties.