CHIZ27 Welcome NP Children Form

Pediatric Patients - Demographic Form

Please complete the virtual registration. If you don’t, be prepared to spend extra time completing it in the office.
Patient's Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Patient's Gender at Birth
Preferred Pronoun
Race

American Indian/Alaska NativeAsianBlack/African AmericanNative Hawaiian/Pacific IslanderWhiteTwo or more racesOther
Language Preference
Full address where patient lives *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Parent/Guardian's Name - 1*

First NameLast Name
Check one*

Blood ParentLegal ParentStep/Partner ParentFoster ParentLegal Guardian
Mobile Phone Number for Parent/Guardian - 1*
Please enter a valid phone number.
Email for Parent/Guardian - 1*
example@example.com
Birthdate for Parent/Guardian - 1*

MonthDayYear
Date
Can we send/leave you reminders via (check all that apply)*

TextEmailVoicemailAll
Please attach a photo of Parent/Guardian - 1's government issued ID (driver’s license, passport or military ID, etc.). You can use your cell phone to take the picture.

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Parent/Guardian's Name - 2

First NameLast Name
Check one

Blood ParentLegal ParentStep/Partner ParentFoster ParentLegal Guardian
Mobile Phone Number for Parent/Guardian - 2
Please enter a valid phone number.
Email for Parent/Guardian - 2
example@example.com
Birthdate for Parent/Guardian - 2

MonthDayYear
Date
Do ALL of the patient's parents/guardians live in the same household as the patient?

YesNo
If no, name of parent (child doesn't live with)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If no, name of parent (child doesn't live with)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Doctor/Pediatrician's Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Is the referring doctor the same as the patient's primary doctor/pediatrician?

YesNo
Referring Doctor's Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Pharmacy Information
Pharmacy Name*
Cross Streets of Pharmacy*
Family/Friends (that aren’t legal parents) ALLOWED
info and/or to bring to Appointments
Please provide us with step-parents/partners, grandparents, siblings, aunts/uncles and/or friends we can talk to or allow to bring patient to see us:

HIPAA Approved Contacts*

	Name	Phone	Relationship	Date of Birth
1.
2.
3.
4.

Insurance Information
Please attach a photo of the FRONT side of the patient's PRIMARY insurance card. You can use your cell phone to take the picture.

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Please attach a photo of the BACK side of the patient's PRIMARY insurance card. You can use your cell phone to take the picture.

Cancelof
Do you have secondary insurance?

YesNo
Please attach a photo of the FRONT side of the patient's SECONDARY insurance card. You can use your cell phone to take the picture.

Cancelof
Please attach a photo of the BACK side of the patient's SECONDARY insurance card. You can use your cell phone to take the picture.

Cancelof
CEC may disclose all or any part of my medical record and/or financial ledger, including information regarding alcohol or drug abuse, psychiatric illness, communicable disease, or HIV, to any person or corporation (1) which is or may be liable or under contract to CEC for reimbursement for services rendered, and (2) any health care provider for continued patient care. CEC may also disclose on an anonymous basis any information concerning my case, which is necessary or appropriate for the advancement of medical science, medical education, medical research, for the collection of statistical data or pursuant to state or federal law, statue or regulation. A copy of this authorization may be used in place of the original. I authorize that my protected health information (also known as PHI) may be used or disclosed with the above-mentioned people. I understand that I have the right to be aware of all PHI that will be disclosed to these people. I understand that Children’s Eye Care will not condition any aspect of my treatment or payment I understand that I am under no obligation to sign this Authorization. I understand that this Authorization may be revoked in writing at any time by my signing the revocation section below and returning it to Children’s Eye Care unless: they have previously acted in reliance on this Authorization. By my signing the Authorization, I acknowledge that I have read and understand this Authorization. Further, I give my authorization to Children’s Eye Care to use or disclose PHI in accordance to the terms of the Authorization. Financial Agreement: I agree that in return for the services provided to the patient by CEC, I will pay my account at the time service is rendered or will make financial arrangements satisfactory to CEC for payment. If an account is sent to an attorney for collection, I agree to pay collection expenses and reasonable attorney’s fees as established by the court and not by a jury in any court action. I understand and agree that if my account is delinquent, I may be charged interest at the legal rate. Any benefits of any type under any policy of insurance insuring the patient, or any other party liable to the patient, is hereby assigned to CEC. If copayments and/or deductibles are designated by my insurance company or health plan, I agree to pay them to CEC. However, it is understood that the undersigned and/or the patient are primarily responsible for the payment of my bill. Also, I agree to reimburse CEC the fees of any collection agency , which may be based on a percentage at a maximum of 25% of the debt, and all costs, and expenses, including reasonable attorneys’ fees, we incur in such collection efforts.

Our office does NOT participate with VISION insurance. Visits will be billed to the medical plan.
Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Parent/Guardian's Signature*

Clear
Patient/Parent/Guardian's Name
Touchless/Virtual Payment

If you’d like to pay your copay virtually, please click on the link. It will open in a new window, but please come back and complete this form! Thank you! Payment Portal
How to make your exam easier and more efficient:
- Bring all medical insurance cards and your (parent/guardian) driver’s license/ID. We do not participate with vision insurance so we don’t need that card for billing the exam. If your insurance company requires authorization or referral from your primary care doctor, please obtain this authorization for your first visit and for every visit thereafter.
- If the patient already wears glasses, please bring them with you.
- Minor patients must be accompanied by a parent or legal guardian at the initial visit. A waiver can be signed for subsequent visits but it’s always our preference that a parent and/or legal guardian accompanies all children including those old enough to drive themselves.
- If you are a legal guardian /foster parent, please bring legal documentation regarding your relationship.
- Be prepared to pay for any services not covered (copays, deductibles, etc.) by your insurance company using cash, check or credit card. For example, the determination of refraction (to assess if a glasses prescription is/isn’t needed) isn’t covered by some medical plans.
Things to know:
- We have a lot of educational info and videos about pediatric eye exams at Children’s Eye Care’s website (click here for the information and videos in a seperate window).
- Please know that assessing glasses prescriptions doesn’t provide you with the pupil distance (PD) to buy glasses online. That is the responsibility of the place you purchase your glasses from – not the doctor doing the assessment for the lens power needed.
- We don’t do contact lens exams. You would have to see an optometrist for that.
- To most precisely assess children’s vision and eye health, we MUST use drops that dilate their pupils (click here for an explianation in a seperate window) and relax the muscles inside their eyes. This is a critically important part of your child’s exam. Once pupils are fully dilated, our doctors can very quickly check to see if they have a refractive error (hyperopia, myopia, astigmatism) requiring glasses and if there’s any disease in the eye with little to no feedback from the patient. The eye drops take at least 30 minutes (and longer for some children) to work, so plan for your visit to take about two hours. It’s normal for your child’s vision to be blurry for four to 24 hours after using the drops, but the child will still be able to function. Just bring sunglasses in case the child is light-sensitive.
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