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KID FORMS

online forms

Madison Pediatrics



New Patient Information Form

(Fill. Submit. Done.)



Date: *
CalendarNow(GMT - 05.00)


Child Information
 
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Parent or Legal Guardian Information

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Patient's Family / Household Members

Please list family members, their relationship to the child, and whether or not they live in the same household.
1)

(First Middle Last)




Lives in same home:


2)

(First Middle Last)




Lives in same home:


3)

(First Middle Last)




Lives in same home:


4)

(First Middle Last)




Lives in same home:


5)

(First Middle Last)




Lives in same home:


6)

(First Middle Last)




Lives in same home:


7)

(First Middle Last)




Lives in same home:


8)

(First Middle Last)




Lives in same home:


9)

(First Middle Last)




Lives in same home:



Primary Insurance Information

(Insurance information required, if applicable.)
Check if Self Pay/No Insurance:













Check if address same as Parent/Guardian above:






Secondary Insurance Information

Check if No Secondary Insurance:













Check if address same as Parent/Guardian above:





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I hereby assign all medical and/or surgical benefits, including all major medical benefits to which I am entitled (Medicaid, private insurance, or any other health benefits plan) in relation to the above child's medical care as provided by the staff of Madison Pediatrics to Madison Pediatrics, Inc., and Dr. Gregg M. Alexander. This assignment will remain in effect until revoked by me in writing. A copy of this assignment is considered as valid as the original. I understand that some charges are not fully covered by Medicaid or other insurance plans and I acknowledge that I am financially responsible for any such fees as legally apply. I hereby authorize Madison Pediatrics, Inc., to release all information necessary to secure appropriate payments for any and all services rendered. I authorize Madison Pediatrics, Inc., and/or any entity authorized by them, including those using automated dialing systems, automated messages, email, text messaging or other electronic communication to contact me for any reason by using any telephone number, email address and/or mailing address provided.


By signing this form (typed signature), you are certifying the accuracy of this information and agreeing to send the information to Madison Pediatrics, Inc., for inclusion into your child's records.