Pediatric Consultants of Ashland and Mansfield
Pediatric Consultants of Ashland and Mansfield
Insurance Change Form
Patient Name:
Patient Name:
First
Middle
Last
Date of Birth:
Date of Birth:
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Siblings who are patients at Pediatric Consultants
affected by change
:
Siblings who are patients at Pediatric Consultants
affected by change
:
First
Middle
Last
Sibling Date of Birth:
Sibling Date of Birth:
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MM
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DD
YYYY
Sibling Name:
Sibling Name:
First
Middle
Last
Sibling Date of Birth:
Sibling Date of Birth:
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MM
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DD
YYYY
Sibling Name:
Sibling Name:
First
Middle
Last
Sibling Date of Birth:
Sibling Date of Birth:
/
MM
/
DD
YYYY
Sibling Name:
Sibling Name:
First
Middle
Last
Sibling Date of Birth:
Sibling Date of Birth:
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MM
/
DD
YYYY
Parent E-Mail Address:
Name of
Primary
Insurance:
Policy/Billing number:
Group number:
Effective Date:
Effective Date:
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MM
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DD
YYYY
Policyholders Employer:
***Name of
Previous
Insurance:
***Date
Previous
Insurance Ended:
Name of
Secondary
Insurance: (if applicable)
Policy/Billing number:
Group number:
Name of Policyholder:
Name of Policyholder:
First
Middle
Last
Policyholders Date of Birth:
Policyholders Date of Birth:
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MM
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DD
YYYY
Effective Date:
Effective Date:
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MM
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Financial Responsibility and Assignment of Benefit:
I authorize payment directly to Pediatric Consultants of Ashland and Mansfield for all medical and surgical benefits under the terms of my insurance.
I understand that I am financially responsible for all co-payments and any charges not paid by my insurance or Ohio Medicaid/Managed Care Program.
I have received a copy of the policies and procedures. A photocopy of this authorization shall be considered as effective and valid as the original. I understand that if my child's physician, or any person employed by or under the direction and control of my child's physicians(s), is directly exposed to my child's body fluids in any manner which may, according to the then current guidelines for the Center of Disease Control, transmit the human immunodeficiency virus (HIV) or hepatitis B or C viruses, that I am deemed by law to have consented to testing for infection with HIV or hepatitis B or C viruses. I further understand that by law I will have deemed to consent to the release of these test results to the person who is exposed to my child's body fluids.
Name of Parent/Personal Representative:
Name of Parent/Personal Representative:
First
Middle
Last
Signature of Parent/Personal Representative:
Clear
Relationship to Patient:
Date:
Date:
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DD
YYYY