Get Patient Identification Sheet - Bixby Pediatrics

Filling out the Patient Identification Sheet is an important step for ensuring that your child receives the appropriate care at Bixby Pediatrics. This comprehensive guide will walk you through each section of the form to help you complete it accurately and efficiently online.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's name and birth date in the designated fields at the top of the form. This information is essential for identifying your child within the practice.
3. Next, fill in the date your child was first seen and the name of the referring individual if applicable. Additionally, provide details regarding the child's race and sex.
4. Provide the father's name, Social Security Number, and birth date. Additionally, enter the father's address, home phone number, cell number, employer, and work number where applicable.
5. Repeat the above step for the mother, including her name, Social Security Number, birth date, address, home phone, cell number, employer, and work number.
6. Indicate the preferred phone number for contact by entering the relevant number in the specified section.
7. List any other children in the family by filling in their names and birth dates in the provided fields, up to five children.
8. Fill out the emergency contact information, including the name, relation, and phone number of the designated contact person.
9. Enter the guarantor’s name and relationship to the patient. Include any necessary details regarding insurance coverage, such as the insurance company name, effective date, policy holder's name, birth date, relationship, group number, member ID, and co-pay information.
10. If applicable, repeat the insurance information section for secondary insurance coverage, providing similar details as above.
11. Read through the insurance authorization and assignment section carefully. Sign and date the form where indicated, ensuring to provide your relationship to the patient.
12. Finally, save your changes, download a copy for your records, or print the form as needed. You may also share the completed form with relevant parties.

Complete your patient's identification sheet online for a seamless experience at Bixby Pediatrics.