New Patients Form

You may print these documents and bring them with you during your first visit, for faster paperwork processing. These can also be filled out at our office, if you do not have access to a printer.

Patient Information — This form may be completed online: see below
Acknowledgement of Privacy Practices
Release of Information
Financial Policy
Services Not Covered
Notice of Privacy Practices (HIPPA)

Note: in order to view these documents, you will need a PDF Reader, a free download from Adobe.com.

Please fill out the New Patient Form below; required fields are marked with an asterisk (). Social security and driver's license number will be entered on the printed version of this form.

Patient Information
Minor/Child Information
Last Name
First Name
Middle Name
Nickname
Sex
Date of Birth
Social Security #	___________________________
	Please enter SSN# on the printed form
Home Address
Address
City, State, Zip
Billing Information
Billing Address
Address
City, State, Zip
Home Phone #
Father's Phone #
Mother's Phone #
Father/Guardian Information
Name
Address (if different from billing)
Home Phone #
Work Phone #
Employer
Date of Birth
Driver's Licence #	___________________________
Social Security #	___________________________
	Please enter DL# and SSN# on the printed form
Mother/Guardian Information
Name
Address (if different from billing)
Home Phone #
Work Phone #
Employer
Date of Birth
Driver's Licence #	___________________________
Social Security #	___________________________
	Please enter DL# and SSN# on the printed form
Insurance Information
The information below is optional, but will help us process your information faster when you arrive.
Insured Person's Name
Insurance Company Name
Insurance ID #
Policy Group #
Emergency Contacts
In the event of an emergency, whom should we contact? (Someone other than the parent or guardian)
Emergency Contact # 1
Name
Relationship to Patient
Phone #
Emergency Contact # 2
Name
Relationship to Patient
Phone #
Release and Assignment
Because your child is a minor, it becomes necessary that a signed permission be obtained from a parent/guardian before any and/or all necessary medical services can be started and accomplished by the physicians at University Pediatric Association. I authorize the release of any medical or other information required in the processing of claims. I authorize my insurance benefits to be paid directly to the health care provider. My signature as parent/guardian affixed below authorizes the rendering of medical services. This consent shall remain in full force and effect until cancelled by either party. I understand that I am financially responsible for all charges incurred as a result of medical services rendered. In my absence, the following persons may present my child for medical treatment:

Signature of Parent/Guardian	___________________________
Date	___________________________
	Please sign and date the printed form
Also print a copy of this form (bringing a printout will speed up the processing of your information)

University Pediatrics Association
1602 Rock Prairie Road - College Station, TX 77845
Online: www.University-Pediatrics.com
Phone: (979) 696-4440

University Pediatrics Association, College Station Texas

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