Registration Form

"*" indicates required fields

Patient Name*
Birthday*
Sex*
Race*
Ethnicity*
Primary Language*
Address*
BEST phone number is*
SECOND phone number is
EMERGENCY phone number is*
Father's Birthdate*
Mother's Birthdate*

Financial Policy/Agreement

We are contracted with many insurance carriers and are pleased to bill them directly for you. Once your primary insurance has processed your claim, we will then bill your secondary insurance with a copy of your explanation of benefits. If a copayment or deductible is part of your plan, we require that your portion is paid at the time of service.

Co-payments:

Are due at the time of service. A $10 processing fee will be charged in addition to your co-payment if the co-payment is not paid at the time of service or by the end of our business day.

Private Pay Patients:

If you have no medical insurance, payment for services is to be paid at the time of the visit, unless arrangements have been made with our financial department.

By signing, I hereby authorize the release of any medical information to insurance carriers needed to process a claim and request payment be made directly to Pacific Coast Pediatrics for medical services rendered to my child. I understand that I am financially responsible for all charges not covered by my insurance, and that I must pay my portion within 30 days after my insurance has processed my claim.

Returned Checks: There is a $25 fee for any checks returned by the bank.

Name of Parent or legal Guardian*
Date*
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