Patient Demographics

Please fill out this form as completely as possible. It will be sent securely to our office.

You will be asked to provide photos of the front and back of your insurance card(s), as well as the front of your driver’s license or state ID.

"*" indicates required fields

Household Structure

Do all the children in your family live in the same household?*

Do they live at the same address, with the same parents/guardians and the same insurance plan?

Yes

Use this one form to register up to five children living in the same household.

If you have a blended family with children in separate households with different addresses, parents/guardians, and/or different insurance plans, then you must complete this form for EACH HOUSEHOLD.

How many children are you registering on this form?*

You can register up to five children on one form. All children on this form must live at the same address, with the same parents/guardians and the same insurance plan.

Patient 1

P1 Name*

First Middle Last

P1 Nickname

P1 Preferred Language

P1 DOB*

P1 SSN

P1 Gender*

Assigned at birth

Male

Female

P1 Race*

Asian

Black

White

Other

P1 Ethnicity*

Hispanic

Non-Hispanic

Unknown

P1 Cell Phone

If age is > 12

P1 Email

If age is > 12

Patient 2

P2 Name*

First Middle Last

P2 Nickname

P2 Preferred Language

P2 DOB*

P2 SSN

P2 Gender*

Assigned at birth

Male

Female

P2 Race*

Asian

Black

White

Other

P2 Ethnicity*

Hispanic

Non-Hispanic

Unknown

P2 Cell Phone

If age is > 12

P2 Email

If age is > 12

Patient 3

P3 Name*

First Middle Last

P3 Nickname

P3 Preferred Language

P3 DOB*

P3 SSN

P3 Gender*

Assigned at birth

Male

Female

P3 Race*

Asian

Black

White

Other

P3 Ethnicity*

Hispanic

Non-Hispanic

Unknown

P3 Cell Phone

If age is > 12

P3 Email

If age is > 12

Patient 4

P4 Name*

First Middle Last

P4 Nickname

P4 Preferred Language

P4 DOB*

P4 SSN

P4 Gender*

Assigned at birth

Male

Female

P4 Race*

Asian

Black

White

Other

P4 Ethnicity*

Hispanic

Non-Hispanic

Unknown

P4 Cell Phone

If age is > 12

P4 Email

If age is > 12

Patient 5

P5 Name*

First Middle Last

P5 Nickname

P5 Preferred Language

P5 DOB*

P5 SSN

P5 Gender*

Assigned at birth

Male

Female

P5 Race*

Asian

Black

White

Other

P5 Ethnicity*

Hispanic

Non-Hispanic

Unknown

P5 Cell Phone

If age is > 12

P5 Email

If age is > 12

Patient Addresses

Physical Address*

Street Address City State Zip Code

Mailing Address

Street Address City State Zip Code

Primary Contact

C1 Name*

First Middle Last

C1 DOB*

C1 SSN*

C1 Relationship*

C1 Marital Status

C1 Employer

C1 Occupation

C1 Email

C1 Primary Phone*

C1 Primary Phone Mobile

This is a mobile phone

C1 Work Phone

C1 Work Phone Mobile

This is a mobile phone

C1 Physical Address Same as Patient*

Yes

C1 Physical Address*

Street Address City State Zip Code

C1 Mailing Address Same as Patient*

Yes

C1 Mailing Address*

Street Address City State Zip Code

C1 Appointments Contact Preferences*

Select all that apply. All statements will be sent by US Mail.

Primary Phone

Work Phone

Text Message

C1 Medical/Billing Contact Preferences*

Select all that apply. All statements will be sent by US Mail.

Primary Phone

Work Phone

Text Message

Secondary Contact

C2 There is no secondary contact

There is no secondary contact

C2 Name*

First Middle Last

C2 DOB*

C2 SSN*

C2 Relationship*

C2 Marital Status

C2 Employer

C2 Occupation

C2 Email

C2 Primary Phone*

C2 Primary Phone Mobile

This is a mobile phone

C2 Work Phone

C2 Work Phone Mobile

This is a mobile phone

C2 Physical Address Same as Patient*

Yes

C2 Physical Address*

Street Address City State Zip Code

C2 Mailing Address Same as Patient*

Yes

C2 Mailing Address*

Street Address City State Zip Code

C2 Appointments Contact Preferences*

Select all that apply. All statements will be sent by US Mail.

Primary Phone

Work Phone

Text Message

C2 Medical/Billing Contact Preferences*

Select all that apply. All statements will be sent by US Mail.

Primary Phone

Work Phone

Text Message

Billing

B_Responsible Party*

Patient

Primary Contact

Secondary Contact

Other

B_Name*

First Middle Last

B_Relationship*

B_Email

B_Primary Phone

B_Primary Phone Mobile

This is a mobile phone

B_Work Phone

B_Work Phone Mobile

This is a mobile phone

B_Mailing Address*

Street Address City State Zip Code

Legal Information

L_Custodial Parent

If parents are divorced or separated, who has custody?

L_Legal Restrictions

Are there any legal restrictions that would restrict the noncustodial parent from consenting to medical treatment for the child or from obtaining information about the child’s medical treatment?

Yes

L_Other*

If yes, please explain and provide a copy of any legal paperwork that supports this restriction.

Emergency Contact (Not a Parent)

C3 Name*

C3 Relationship*

C3 Email

C3 Phone*

C3 Phone Mobile

This is a mobile phone

Insurance Primary Carrier

I1 Flag*

Do you have medical insurance?

Yes

I1 Carrier*

I1 Policy Holder Name*

I1 DOB*

I1 SSN*

I1 Gender*

Male

Female

I1 Employer*

I1 ID*

I1 Group*

Front of Insurance Card*

Please upload a copy of the front of your insurance card, or take a picture using your phone.

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 5 MB.

Back of Insurance Card*

Please upload a copy of the back of your insurance card, or take a picture using your phone.

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 5 MB.

Insurance Secondary Carrier

I2 Flag

Do you have a secondary insurance carrier?

Yes

I2 Carrier*

I2 Policy Holder Name*

I2 DOB*

I2 SSN*

I2 Gender*

Male

Female

I2 Employer*

I2 ID*

I2 Group*

Front of Insurance Card*

Please upload a copy of the front of your insurance card, or take a picture using your phone.

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 5 MB.

Back of Insurance Card*

Please upload a copy of the back of your insurance card, or take a picture using your phone.

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 5 MB.

Driver's License or State ID

Front of Driver's License*

Please upload a copy of the front of your driver's license or state ID, or take a picture using your phone.

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 5 MB.

Preferred Pharmacy

Pharmacy Name

Pharmacy City

Pharmacy Phone

Signature

I request that payment of authorized Medicaid and/or commercial insurance bene! ts be made to Fairhope Pediatrics, Inc. for any service furnished to me or my dependent by Fairhope Pediatrics’ providers. I authorize Fairhope Pediatrics, Inc. to release medical information which may be required by my insurance carrier to determine payment for services rendered. I further understand that I am responsible to pay certain amounts due the physician. These amounts could include annual deductibles, copayments, charges denied as not covered by Medicaid or my commercial insurance carrier, and charges denied for services determined as not medically necessary. I further understand that if Fairhope Pediatrics, Inc. incurs any fees associated with collecting reimbursement on my account, I will be responsible for paying all of those fees.

S_Relationship*

Parent/Guardian Signature*

This field is hidden when viewing the form

Date

Name

This field is for validation purposes and should be left unchanged.

Patient Demographics

Household Structure

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

Patient Addresses

Primary Contact

Secondary Contact

Billing

Legal Information

Emergency Contact (Not a Parent)

Insurance Primary Carrier

Insurance Secondary Carrier

Driver's License or State ID

Preferred Pharmacy

Signature

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