Get Minor New Patient Form - 2016

Completing the Minor New Patient Form - 2016 online is a straightforward process that ensures all necessary information is collected for your minor child's medical care. This guide will walk you through each section of the form, making it easy for you to provide accurate and complete information.

Follow the steps to fill out the Minor New Patient Form - 2016 online.

1. Press the ‘Get Form’ button to gain access to the Minor New Patient Form - 2016 and open it in your preferred document editor.
2. Begin by entering the preferred site for future appointments, selecting from the options provided.
3. Fill in the minor’s full name, gender, and date of birth in the designated fields.
4. Provide the primary contact's name, phone number, preferred language, race, and social security number.
5. Indicate the relationship of the primary contact to the minor child and select their preferred contact number.
6. Complete the responsible party/guarantor fields with their full name, relationship to the minor, date of birth, social security number, and contact information.
7. For additional contact or parent information, fill out the required fields or select the option to use the same address as the responsible party.
8. Input the primary insurance information, including the name of the insurance provider, copay amount, group number, and ID number.
9. If there is a policyholder other than the minor, provide their details, including full name, social security number, and contact information.
10. Repeat the previous step for any secondary insurance information, if applicable.
11. Review and initial the authorization for release of information and financial responsibility section, ensuring all required signatures are completed.
12. Finally, save your changes, download, print, or share the completed form as needed.

Start filling out your Minor New Patient Form - 2016 online today!