NEW PATIENT OFFICE POLICY SIGNATURE FORM

For your convienence, print and complete form below to expedite new patient registration at your first visit.

Thank you for choosing BEACH PEDIATRICS to care for your child. We welcome you to the practice and look forward to caring for your child. Please take a moment to read the following and sign acknowledgment at the bottom of each page. Be sure to contact your insurance company (if applicable) to inform them that you have chosen BEACH PEDIATRICS for your primary care physician.

Our office complies with HIPPA Regulations, also known as patient privacy rights. This policy is posted throughout the office. If you would like a copy please request one from the reception area.

As you are probably aware, in recent years the number of different health insurance programs has increased at an amazing rate. Even within one company there may be several programs with varying benefits and requirements. Although our staff keeps as up to date as possible there is no way to ensure complete accuracy at all times with each program’s individual provisions. Be sure to contact your insurance directly with any questions regarding your coverage.

Helpful facts to know about your insurance:
☐ Is prior authorization required?
☐ Are you, as the patient or parent required to notify them of hospital admissions or trips to the emergency room?
☐ Is a referral required to see a specialist?
☐ Is there a designated facility to be for diagnostic testing?
☐ Is there a co-pay for services rendered?

There are times that a service is not covered by your insurance and may be offered within the office for a fee. If you prefer to have these services, please let us know and we will advise you of the cost.

Our friendly staff will gladly assist you with any questions or concerns you may have.

Please advise the office of any specific concerns or questions. Thank you.

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