NEW REGISTRATION

PATIENT INFORMATION

Sex


REASON FOR THE VISIT

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INSURANCE

Do you have Insurance?

Pharmacy Information



HOW DID YOU HEAR ABOUT US?

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EMERGENCY CONTACT

(Medical Information may be released to this contact)

Relationship to Patient


DECLARATION / TERMS AND CONDITIONS

(Kindly accept the following terms and conditions before submission of forms)

Financial Policy

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to JB Healthcare LLC d/b/a Little Star Pediatrics. I understand that I am financially responsible for any balance. I also authorize JB Healthcare LLC d/b/a Little Star Pediatrics or my insurance company to release any information required to process my claims.

Authorization to view and obtain external prescription history

I authorize the medical providers of JB Healthcare LLC d/b/a Little Star Pediatrics to view and obtain my child’s external prescription history via electronic prescription services. I understand that prescription history from multiple other unaffiliated medical providers, insurance companies, and pharmacy benefit managers may be viewable by my providers and staff through these services, and may include prescriptions back in time for several years.

Notice of privacy practices

I certify that I have received a copy of Notice of Privacy Practices. The Notice of Privacy Practices describes the types of uses and disclosures of my child’s protected health information that might occur in my treatment, payment of my bills or in the performance of JB Healthcare LLC d/b/a Little Star Pediatrics . The Notice of Privacy Practices also describes my child’s rights and JB Healthcare LLC d/b/a Little Star Pediatrics’ duties with respect to my child’s protected health information. The Notice of Privacy Practices can also be found on theJB Healthcare LLC d/b/a Little Star Pediatricswebsiteat littlestarpeds.com. JB Healthcare LLC d/b/a Little Star Pediatrics reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail, asking for one at the time of my next appointment, or accessing the practice website



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Kindly check again if you have entered the correct details before submission. No correction from this point forward.

At the submission of this form, we will contact you shortly, or you could check-in at our clinic. The generated form would be sent to your given email address.