Parent Demographics for Flu Vaccine

PATIENT INFORMATION
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address City State / Province / Region ZIP / Postal Code
Gender*
- Male
- Female
Additional Information
Driver's License Number*
Email*
Employer Name*
Employer Phone Number*
Home Phone Number*
Mobile Phone Number
EMERGENCY CONTACT INFORMATION
(other than parents)
Name*
First Last
Relation*
Phone Number*
PRIMARY INSURANCE INFORMATION
Responsible Person/Guarantor
Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Social Security Number*
Name of Employer*
Employer Address*
Street Address City State / Province / Region ZIP / Postal Code
Employer Phone Number*
Insurance Name*
Policy ID*
Group Number*
Preventive Coverage*
- Yes
- No
Co-Payment*
SECONDARY INSURANCE INFORMATION
Responsible Person/Guarantor
Name
First Middle Last
Date of Birth
MM slash DD slash YYYY
Social Security Number
Name of Employer
Employer Address
Street Address City State / Province / Region ZIP / Postal Code
Employer Phone Number
Insurance Name
Policy ID
Group Number
Preventive Coverage
- Yes
- No
Co-Payment
AGREEMENT OF FINANCIAL RESPONSIBILITY
Thank you for choosing St. Clair Pediatrics as your child's health care provider. We are committed to providing quality care and service to all of our patients. The following is a statement of our financial policy, which we require that you read and agree to prior to any treatment.

Please understand that payment of your bill is considered part of your treatment. Fees are payable when services are rendered. We accept cash, check, credit cards, and pre-approved insurance for which we are a contracted provider and are the designated Primary Care Provider (PCP), if applicable.

It is your responsibility to know your own insurance benefits, including whether we are a contracted provider with your insurance company, your covered benefits and any exclusions in your insurance policy, and any preauthorization requirements of your insurance company.

We will attempt to confirm your insurance coverage prior to your treatment. It is your responsibility to provide current and accurate insurance information, including any updates or changes in coverage. Should you fail to provide this information, you will be financially responsible.

If we have a contract with your insurance company we will bill your insurance company first, less any copayment(s) or deductible(s), and then bill you for any amount determined to be your responsibility. This process generally takes 45-60 days from the time the claim is received by the insurance company.

If we do not contract with your insurance company, you will be expected to pay for all services rendered at the end of your visit. We will provide you with a statement that you can submit to your insurance company for reimbursement.

Proof of payment and photo ID are required for all patients. We will ask to make a copy of your ID and insurance card for our records. Providing a copy of your insurance card does not confirm that your coverage is effective or that the services rendered will be covered by your insurance company.

Please understand some insurance coverages have Out-of-Network benefits that have co-insurance charges, higher co-payments and limited annual benefits. If you receive services are part of an Out-of-Network benefit, your portion of financial responsibility may be higher than the In-Network rate. I have read the financial policies contained above, and my signature below serves as acknowledgement of a clear understanding of my financial responsibility. I understand that if my insurance company denies coverage and/or payment for services provided to me, I assume financial responsibility and will pay all such charges in full.
I understand and accept the above statement.*
- I agree
Patient/Responsible Party Name*
First Middle Last
Date*
MM slash DD slash YYYY
E-Signature*
First Last

What Our Families Are Saying

Hollie H.

Dr. Garrison and his staff are just the best!!!! I could not ask for a better pediatrician for my son!! I would highly recommend them to anyone!

Catrina H.

We just switched to them and I’m so glad we did! The office is beautiful and clean and everyone there is very friendly and helpful.

Karen R.

As stressful as it can be to bring your sick child into the pediatrician’s office, the staff at St. Clair Pediatric’s always know how to provide a calm & comforting environment! The care provided by their staff is nothing short of spectacular.