White Oak Pediatrics
White Oak Pediatrics

Patient Information
Middle Name
Last Name
 First Name
Date of Birth
 Sex
Responsible for Payment (Guarantor)
First Name
 Middle Name
Last Name        
Sex
Social Security #
Date of Birth
Home Street Address
City,State
Relation to Patient
Home Telephone
Cell Phone
Primary Insurance Information
Insurance Company Name
ID/Policy Number
Group Number
Policy Holder Date of Birth
Policy Holder Name
Policy Holder
Policy Holder Relationship to Patient
Contact (other parent or contact if applicable)
Last Name
 First Name
Middle Name
Relationship to Patient
City, State
Home Street Address
Cell Telephone
Home Telephone
 Work Telephone
I
certify that all of the above information is complete
and accurate and will notify the office of any changes.  I agree that I will be
responsible for the consequenses of innaccurate information (billing wrong
insurance, wrong lab, etc).  I also certify that NO OTHER HEALTH COVERAGE
EXISTS AT THIS TIME OTHER THAN THE ONE ABOVE.  I understand it may
be illegal not to disclose the existence of a health care coverage.  I
understand IT IS MY RESPONSIBILITY TO INFORM White Oak Pediatrics
immediately should a change in health care coverage occur at any time in the
future.  I understand that I am ultimately responsible for all charges whether
or not covered by my insurance.
Date
Electronic Signature
White Oak Pediatrics