Page Title

Patient Information

Child’s last name________________________ &= nbsp; First Name________________________________

Referred by:____________________________ &n= bsp; Sex: M / F = Date of Birth:__________________

Address:_______________________________ &nb= sp; City:___________ State:______ Zip:___________<= /p>

Phone Number:__________________________

Parent/ Legal Guardian Information

Last name______________________________ &nb= sp; First Name _________________ &= nbsp; DOB: _________

Address:_______________________________ &nb= sp; City:___________ State:______ Zip: ___________<= /span>

Phone Number:__________________________ &nb= sp; SSN:_______________________________

Employer:______________________________ &nb= sp; Employer Phone Number:______________

Emergency Contact

Last name______________________________ &nb= sp; First Name _________________ DOB: _________

Address:_______________________________ &nb= sp; City:___________ State:______ Zip: ___________<= /span>

Phone Number:__________________________

Guarantor Information:

Last name______________________________ &nb= sp; First Name _________________ DOB: _________

Relationship to the patient:_________________ &nb= sp; SSN:______________________ &nb= sp;

Employer:______________________________ &nb= sp; Name of Insurance:____________________

Insurance ID #: _________________________ &= nbsp; Group #: ____________________________

Insurance Assignment and Relea= se

I certify that I have insurance= with_____________________________ and assign directly to Dr. Rajeev Agarwa= l all insurance benefits, if any, otherwise payable to me for services rend= ered. I understand that I am financially responsible for all charges = whether or not paid by insurance. I authorize the use of my signature= on all insurance submissions.

The above-named doctor may use = my health care information and may disclose such information to the above n= amed Insurance Company(ies) and their agents for the purpose of obtaining p= ayment for services and determining insurances benefits or the benefits pay= able for related services. This consent will remain in effect till sp= ecifically requested as such by me.

Medicare Authorization

I request that payment of autho= rized Medicare benefits and, if applicable, Medigap benefits, be made eithe= r to me or on my behalf to Dr. Rajeev Agarwal dba Desert Ridge ChildrenR= 17;s Center.

To the extent permitted by law,= I authorize any holder of medical or other information about my child to r= elease to the Centers for Medicare and Medicaid Services, my Medigap insure= r, and their agents any information needed to determine these benefits or b= enefits for related services.=

<= /p>

Signature of Parent, Guardian o= f Personal Representative:________________________________________

Date:__________________________= __Relationship to Patient;___________________________________