Get Patient Registration Minor

This guide will help you navigate the PATIENT REGISTRATION MINOR form to ensure that all necessary information is accurately collected. Completing this form online allows for a convenient and efficient registration process for your minor's medical care.

Follow the steps to complete the registration form successfully.

1. Press the ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by filling out the patient’s legal name in the specified field, followed by the name of preference or nickname if applicable.
3. Enter the patient's date of birth, sex, and social security number in the respective fields.
4. Indicate the patient’s race and age, then provide today’s date and the preferred language.
5. Select the marital status of the parent or guardian by circling the appropriate option among married, single, divorced, or widowed.
6. Fill in the home or mailing address, including city, state, and zip code, circled as applicable.
7. If there is a different mailing address, provide that information along with the required details.
8. List the referring physician’s name and their contact number.
9. Provide the mother’s and father’s names, their dates of birth, mailing addresses if different, and their corresponding phone numbers (home, work, cell) and employer information.
10. Complete the primary and secondary insurance information by filling out the plan name, claims address, ID number, policy holder status, and group number.
11. After filling out all sections, review the financial information and release of information agreements to ensure understanding and compliance.
12. Finally, sign and date the form where indicated for both the patient and guardian to confirm the provided information is accurate and complete.
13. Once completed, save any changes made to the form. Use the options to download, print, or share the completed form as needed.

Complete your documentation effectively by filing the PATIENT REGISTRATION MINOR online today.