Pediatría

Inscripción

Para rellenar este formulario, necesitarás la siguiente información y/o documentación:

➞ Datos demográficos del paciente (incluido el número de la Seguridad Social)
➞ Tarjeta(s) de seguro médico, dental y/o de visión
➞ Padre, madre o tutor (datos demográficos | número de la seguridad social | documento de identidad o carné de conducir | autorización para el tratamiento médico del menor, si rellena el formulario otra persona que no sea el padre o la madre con la custodia legal)
➞ Identificación tribal, si procede

Por favor, asegúrate de que tienes preparados todos los documentos apropiados antes de rellenar los formularios. Si tu pantalla permanece inactiva durante más de una hora, el sistema se cerrará automáticamente y tus formularios no se guardarán.

Pediatric Registration

"*" señala los campos obligatorios

Are you interested in obtaining services for Children's Behavioral Health?

Yes

Patient Demographics

Name*

Nombre Apellidos

Name

Segundo nombre

Preferred Name

Preferred Pronouns

Assigned Sex at Birth*

Gender Identity*

Date of Birth*

Social Security Number*

Refusing to provide a patient and / or policyholder's social security number can cause delays in your insurance company processing claims. If your insurance company is unable to remit payment for services rendered because they cannot confirm your identity, you will be responsible for all charges.

Are you a member of an American Indian or Alaska Native Tribe or descendant of an enrolled member of an American Indian or Alaska Native?*

If Yes, Name of Tribe*

Upload Tribal Documentation*

Tamaño máximo de archivo: 10 MB.

If you do not have your tribal documentation, please select No, and bring to your first appointment. Staff will update once documentation is provided.

Mailing Address*

Dirección Ciudad Provincia Código Postal

Primary Phone*

May We Leave a Message?*

Yes

Email Address*

When did you move to current community?*

Current county*

Place of Birth*

Ciudad Provincia

Can you access internet?*

Yes

Secondary phone number

Religious preference

Father's Name*

Nombre Apellidos

Father's Employer

Father's Employer Phone

Mother's Name*

Nombre Apellidos

Mother's Employer

Mother's Employer Phone

Emergency Contact 01

Other than Parent

Name*

Nombre Apellidos

Address*

Dirección Ciudad Provincia Código Postal

Emergency Contact 01

Primary Phone*

Emergency Contact 01

Relationship to Patient*

Emergency Contact 01

Add Another Emergency Contact?*

Emergency Contact 02

Other than Parent

Name*

Nombre Apellidos

Address*

Dirección Ciudad Provincia Código Postal

Emergency Contact 02

Primary Phone*

Emergency Contact 02

Relationship to Patient*

Emergency Contact 02

Patient Information

Are you employed?

Yes

Employer Name

Employer Phone

Ethnicity*

Race*

American Indian / Alaska Native

Asian

Black / African American

Native Hawaiian or Other Pacific Islander

White

Decline to Answer

Otra

Number in Household*

Total Number in Household*

Do you have an Identification card or driver’s license?*

N/A

Yes

ID or Driver's License Upload*

Tamaño máximo de archivo: 10 MB.

Next of Kin Information

Name*

Nombre Apellidos

Address*

Dirección Dirección 2 Ciudad Provincia Código Postal

Relationship to Patient*

Patient Information Cont.

Preferred Language*

Do you need an interpreter?*

Yes

Do You Have Health Insurance?*

Health Insurance Information

Which Health Insurance Services Do You Have?*

Medical (Complete Below Form)

Dental (Complete Below Form)

Vision (No Form to Complete)

Uninsured / Cash Pay

Select All that Apply

Primary Medical Insurance

Do You Have Medical Insurance Card to Upload?*

If you do not have an insurance card to upload prior to your appointment, please fill out insurance details and bring insurance card(s) to your first appointment. As a reminder, without proper insurance verification, you can be held responsible for any financial charges accrued.

Insurance Card Upload (Medical)*

Tamaño máximo de archivo: 10 MB.

Insurance Co. Name (Medical)*

Insurance Co. Address (Medical)*

Dirección Ciudad Provincia Código Postal

Insurance Co. Phone (Medical)*

Member No. (Medical)*

Group No. (Medical)*

Last Name (Medical)*

Policyholder’s Information

First Name (Medical)*

Policyholder’s Information

Middle Name (Medical)

Policyholder’s Information

Legal Sex (Medical)*

Policyholder’s Information

Date of Birth (Medical)*

Policyholder’s Information

Do You Have Other Medical Insurance?*

Other Medical Insurance

Do You Have Other Medical Insurance Card to Upload?*

Insurance Card Upload (Other Medical)*

Tamaño máximo de archivo: 10 MB.

Insurance Co. Name (Other Medical)*

Insurance Co. Address (Other Medical)*

Dirección Ciudad Provincia Código Postal

Insurance Co. Phone (Other Medical)*

Member No. (Other Medical)*

Group No. (Other Medical)*

Last Name (Other Medical)*

Policyholder’s Information

First Name (Other Medical)*

Policyholder’s Information

Middle Name (Other Medical)

Policyholder’s Information

Legal Sex (Other Medical)*

Policyholder’s Information

Date of Birth (Other Medical)*

Policyholder’s Information

Primary Dental Insurance

Do You Have Dental Insurance Card to Upload?*

Insurance Card Upload (Dental)*

Tamaño máximo de archivo: 10 MB.

Insurance Co. Name (Dental)*

Insurance Co. Address (Dental)*

Dirección Ciudad Provincia Código Postal

Insurance Co. Phone (Dental)*

Member No. (Dental)*

Group No. (Dental)*

Last Name (Dental)*

Policyholder’s Information

First Name (Dental)*

Policyholder’s Information

Middle Name (Dental)

Policyholder’s Information

Legal Sex (Dental)*

Policyholder’s Information

Date of Birth (Dental)*

Policyholder’s Information

Do You Have Other Dental Insurance?*

Other Dental Insurance

Do You Have Other Dental Insurance Card to Upload?*

Insurance Card Upload (Other Dental)*

Tamaño máximo de archivo: 10 MB.

Insurance Co. Name (Other Dental)*

Insurance Co. Address (Other Dental)*

Dirección Ciudad Provincia Código Postal

Insurance Co. Phone (Other Dental)*

Member No. (Other Dental)*

Group No. (Other Dental)*

Last Name (Other Dental)*

Policyholder’s Information

First Name (Other Dental)*

Policyholder’s Information

Middle Name (Other Dental)

Policyholder’s Information

Legal Sex (Other Dental)*

Policyholder’s Information

Date of Birth (Other Dental)*

Policyholder’s Information

Move On to Parent / Guardian Section*

Click Here

Parent or Guardian

Last Name*

Parent or Guardian

First Name*

Parent or Guardian

Middle

Parent or Guardian

Suffix

Parent or Guardian

Gender Identity*

Parent or Guardian

Primary Phone No.*

Parent or Guardian

May We Leave a Message?*

Yes

Secondary Phone No.

Parent or Guardian

May We Leave a Message?

Yes

Do You Have Same Address as the Patient?*

Address*

Dirección Ciudad Provincia Código Postal

Parent or Guardian

Email Address

Parent or Guardian

Relationship to Patient*

Parent with Legal Custody

Legal Guardian

Foster Out-Of-Home Care

Parent or Guardian

Upload Legal Documentation*

Tamaño máximo de archivo: 10 MB.

Parent or Guardian

EXAMPLES: Court order signed by Judge, or letter from Child Support Services, or Licensed Foster Agency

DISCLAIMER: Without proper legal documentation that indicates you have authorization to seek medical treatment for the minor patient, you cannot complete this form.

Marital Status*

Parent or Guardian

Ethnicity*

Parent or Guardian

Race*

American Indian / Alaska Native

Asian

Black / African American

Native Hawaiian or Other Pacific Islander

White

Decline to Answer

Otra

Parent or Guardian

ID Card Upload*

Tamaño máximo de archivo: 10 MB.

Parent or Guardian

Preferred Language

Parent or Guardian

If Other than English

Do You Need an Interpreter?*

Yes

Parent or Guardian

Move On to Household Questionnaire*

Click Here

Parent or Guardian

Household Questionnaire

Are you a Migrant Agricultural Worker?

Yes

Are You Currently Homeless / Unhoused?

Yes

Do You Have Access to the Internet?

Yes

Total Household Income

Per Year

Move Onto Signatures Section*

Click Here

Patient Signatures

Release of Information Signature*

Release of information, the Shingle Springs Health & Wellness Center has permission to release information needed for insurance processing to my insurance.

Today's Date*

Release of Information

I Certify the Information Provided is True and Accurate.*

Today's Date*

True and Accurate Certification

Pediatría

Inscripción

Para rellenar este formulario, necesitarás la siguiente información y/o documentación:

Pediatric Registration

Patient Demographics

Emergency Contact 01

Emergency Contact 02

Patient Information

Next of Kin Information

Patient Information Cont.

Health Insurance Information

Primary Medical Insurance

Other Medical Insurance

Primary Dental Insurance

Other Dental Insurance

Parent or Guardian

Household Questionnaire

Patient Signatures

Contact Us

Careers

Patient Information

Behavioral Health

Children’s Behavioral Health

Dental

Medical

Pediatrics

Pharmacy

PRC & Specialty Care

Pediatría

Inscripción

Para rellenar este formulario, necesitarás la siguiente información y/o documentación:

Pediatric Registration

Patient Demographics

Emergency Contact 01

Emergency Contact 02

Patient Information

Next of Kin Information

Patient Information Cont.

Health Insurance Information

Primary Medical Insurance

Other Medical Insurance

Primary Dental Insurance

Other Dental Insurance

Parent or Guardian

Household Questionnaire

Patient Signatures

Salud mental

Línea de vida para suicidios y crisis

Centro de atención telefónica en caso de crisis: 9-8-8

Salud conductual infantil

Servicios dentales

Servicios de ortodoncia

Médico

PEDIATRÍA

Servicios farmacéuticos

Programa de recogida de medicamentos

SERVICIOS DE ATENCIÓN ESPECIALIZADA

ACUPUNTURA

QUIROPRÁCTICA

FISIOTERAPIA

PODIATRÍA