Packet for patients five years of age and older - Atlantic Health System

More documents

Recommendations

Info

CHILD DEVELOPMENT CENTER CHILDHOOD HISTORY FORM For Children Ages 5 Years and Older Patient Information Last Name: First Name: DOB: SS#: Sex: Male/Female: Street Address: Race: Religion: City State: Zip Code: County: Home Phone: Primary Care Physician Name: PCP Phone Number: Primary Care Physician Address: Parent/Guardian Information Father/ other DOB: SS# Last Name: First Name: Street Address: City: State: Zip Code: Home Phone: Occupation: Work Phone: Employer’s Name and Address: Mother/other DOB: SS# Last Name: First Name: Street Address: City: State: Zip Code: Home Phone: Occupation: Work Phone: Employer’s Name and Address: Emergency Contact Name & Phone Number 1
Primary Insurance Insurance Company Name: Billing Address City: State: Zip Code: Insured’s Name: Policy Number: Group Number: Phone Number: Secondary Insurance Insurance Company Name: Billing Address City: State: Zip Code: Insured’s Name: Policy Number: Group Number: Phone Number: I authorize release of medical information necessary to process insurance claim(s): I authorize and direct my insurance carrier or it’s intermediaries to issue payment check(s) directly to Morristown Medical Center, Atlantic Health System and agents and/or intermediaries for services rendered. I understand that I am responsible for any amounts not covered by my insurance. Further I understand that your office cannot accept responsibility for collection my claim or for negotiating a settlement on a disputed claim. I am responsible for payment of my account within the limits of our credit policy Signed: ________________________ Date: ____________________ 2
Page 1 and 2: Dear Parent or Guardian: Welcome to
Page 3: For children 5 years of age and old
Page 7 and 8: THIS FORM MUST BE FULLY COMPLETED C
Page 9 and 10: DELIVERY Type of Labor: Spontaneous
Page 11 and 12: SLEEP What time is child’s bedtim
Page 13 and 14: SCHOOL HISTORY Current School Name:
Page 15 and 16: HOME BEHAVIOR All children exhibit,
Page 17 and 18: PEER RELATIONSHIPS Is your child in
Page 19 and 20: ADDITIONAL REMARKS Please write any

Packet for patients five years of age and older - Atlantic Health System

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?