CAP Required Patient Information       

Patient Name:___________________________________________________  Birthday: ___________________

                                Last                                            First                                   MI

Patient Social Security Number: __________________________________________________ (Circle one):  Boy     Girl

Address or legal parent or guardian: ________________________________________________________________

City: ______________________________ State: ________________ Zip: _________________________________

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Responsible Parent or Guardian: __________________________________________________________________

Birthday: _____________________________              SS#:______________________________________________

Home #: ______________________________             Place of Employment: _________________________________

Work #: ______________________________             Message #/Other: ____________________________________

Father’s Name: ____________________________    Mother’s Name: _____________________________________

Second Contact: _______________________________     Home #:  _______________________________________

Work #: ___________________________________      Relationship to patient: ______________________________

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Name of Insurance Company: _____________________________________________________________________

Parent or Guardian who carries child on insurance: _____________________________________________________

ID #: __________________________________       Group #:______________________________________

¨  I have given office staff a copy of my insurance card

¨  I have secondary insurance and I have given the office staff a copy of my card

¨  I have other children that are seen here

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Name                                                                                                                               DOB          

___________________________________________________________________________

Name                                                                                                                               DOB          

I heard about your clinic from:(circle one): Newspaper/Yellow Pages   Friend/Family   Another Dr   Other

 I understand that I am financially responsible for all charges regardless of insurance reimbursement and I agree that I have received a copy of the Central Arkansas Pediatrics financial policy.  I hereby authorize Central Arkansas Pediatrics to release all information necessary to secure the payment of benefits.  I authorize the use of this signature on all insurance claims.

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(Responsible Party)                                                    (Relationship)                                                 (Date)