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Full Spectrum Pediatrics_ P.C

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					                                             Full Spectrum Pediatrics, P.C.
                                                          2841 DeBarr Rd Bldg. A Suite 23
                                                                Anchorage, AK 99508
                                                     Phone: 907-677-1864     Fax: 907-868-5167

                                                          PATIENT REGISTRATION FORM


Patient’s Name: _________________________________________________________ Date of Birth: ______________ Sex: □ M □ F
                                               (Last, First, MI)
Address: __________________________________________________ City/State/Zip: ______________________________________
Home Phone: ___________________ Email Address: _____________________________________ Lives with: □ Mom □ Dad □ Both
Family’s Preferred Language (although we cannot guarantee we can communicate with you): □ English │□ Other: ___________________
Primary Race: □ African American, □ Alaska Native, □ American Indian, □ Asian, □ Caucasian, □ Hispanic, □ Pacific Islander
Ethnicity:(Your culture such as: American, Inuit/Eskimo, Canadian, Russian, Ukrainian, Iraqi, etc.): __________________________
We want to make sure that all our patients get the best care possible, regardless of their race or ethnic background. We would like you to tell us your race or
ethnic background so that we can review the treatment that all patients receive and make sure that everyone gets the highest quality of care.
How did you first hear about our clinic? ____________________________________________________________________________

MOTHER/GUARDIAN
First __________________________ Last_____________________________ MI_____ Date of Birth: ______________ Sex: □ M □ F
Address: ________________________________________________ City/State/Zip: ________________________________________
SSN: ______________________ Home Phone: ________________ Work Phone: ________________ Cell Phone: _______________

FATHER/GUARDIAN
First __________________________ Last_____________________________ MI_____ Date of Birth: ______________ Sex: □ M □ F
Address: ________________________________________________ City/State/Zip: ________________________________________
SSN: ______________________ Home Phone: ________________ Work Phone: ________________ Cell Phone: _______________



PRIMARY INSURANCE
Insurance Company: ___________________________________________________________ Effective Date: ___________________
Claims Mailing Address: ______________________________________________ City/State/Zip: _____________________________
Policy#: ____________________________________________________ Group #:__________________________________________
Subscriber’s Name: ______________________________________________ Date of Birth: ______________________ Sex: □ M □ F
Address: ________________________________________________ City/State/Zip: ________________________________________

SECONDARY INSURANCE
Insurance Company: ___________________________________________________________ Effective Date: ___________________
Claims Mailing Address: ______________________________________________ City/State/Zip: _____________________________
Policy#: ____________________________________________________ Group #:__________________________________________
Subscriber’s Name: ______________________________________________ Date of Birth: ______________________ Sex: □ M □ F
Address: ________________________________________________ City/State/Zip: ________________________________________


Emergency Contact: _________________________________________ Relationship to Patient: _____________________________

Home Phone: ________________________ Work Phone: _______________________ Cell Phone: _________________________


Assignment and Release I, the undersigned, certify that I have provided complete and accurate information on behalf of my family. I assign directly to
Full Spectrum Pediatrics, P.C. all insurance 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 Full Spectrum Pediatrics, P.C. to release all information necessary to secure
payment of benefits. I authorize the use of my signature on all insurance submissions whether manual or electronic.

Responsible Party Signature: _______________________________________________________ Date: _____________________

				
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posted:10/18/2011
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