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Interactive Registration Form

Please fill out the following form prior to your visit to Central Pediatrics. Fields marked by an asterisk (*) are required.

Patient Information

(e.g. 01/30/2000)

Parent/Guardian Information

(e.g. 01/30/2000)

Please enter a email address if you would like to receive the Central Pediatrics Newsletter.

Other Parent/Guardian

(e.g. 01/30/2000)

Please enter a email address if you would like to receive the Central Pediatrics Newsletter.

Primary Insurance

Please enter information for your primary insurance

(e.g. 01/30/2000)

(e.g. 01/30/2000)

Secondary Insurance

If you carry secondary insurance, please fill out the following fields

(e.g. 01/30/2000)

(e.g. 01/30/2000)

Patients 18 years and older

I am 18 years old or older and I authorize Central Pediatrics to communicate with the following [Person] regarding my care and/or the bill for services rendered to me.

I have read and understand the Financial Policy of Central Pediatrics on the bottom of this form. I agree to the terms outlined in this policy and understand that if I do not comply with this policy, my account may be turned over to a collection agency for payment.

I hereby authorize Central Pediatrics to furnish medical treatment to the above-named patient including emergency medical treatment and diagnostic procedures. Authorization is given to Central Pediatrics to release information in connection with illness, treatment or prescription to third party payers and any other parties the clinic shall deem proper.

I hereby assign all medical and/or surgical benefits to which I am entitled to Central Pediatrics for services rendered and understand that I am financially responsible for all charges whether or not paid by my insurance.

Financial Policy:
  1. We ask you to provide us with your current medical insurance card. We will depend on you to notify us of any changes in your insurance coverage.
  2. It is your responsibility to contact your insurance company to check benefits for pediatric services at Central Pediatrics. We bill most types of insurance as a courtesy to our patients, but your insurance plan may deny payment for services or procedures.
  3. We rely on you for settling your account. You are ultimately responsible for all fees relating to your child’s care.
  4. Central Pediatrics does not get involved with divorces or separations. For any patient under 18, the parent who accompanies the minor for their visit will be financially responsible for all charges incurred, including co-pays and deductibles.
  5. Payment is due within 30 days of the date of service. We accept several methods of payment including cash, check, credit cards and debit cards.
  6. All co-payments are due at the time of check-in, along with any deductible or coinsurance amount.
  7. It is your responsibility to obtain referral authorizations from your insurance carrier, if required, and to keep these authorizations up to date and in effect for all of your dates of service.
  8. You agree to report all address, insurance, and/or telephone number changes immediately.
  9. There may be times when the doctor orders laboratory tests that we do not perform in our in-house laboratory. In those cases, the specimen will be sent to the Health East Medical Laboratory (HML) and you will receive a separate bill from the Health East Medical Laboratory (HML) for these services. There will be contact information on that bill so you can phone them with any questions you may have.
  10. There may be times when the doctor orders x-rays to be performed at our office. These x-rays are sent to St. Paul Radiology to be read by a Radiologist. You will receive a separate bill from St. Paul Radiology for these services. There will be contact information on that bill so you can phone them with any questions you may have.
  11. If you do not have any insurance, or your insurance company does not cover services rendered, we require that you make a down payment of $50 towards each office visit. Please remember that this is not payment in full, but a down payment. You will be responsible for all charges accrued on your account, and your $50 will be considered a payment on account.
  12. It is our policy that any patient age eighteen or older will be financially responsible for all charges incurred by them. This means that the account will be placed in that person’s name.

I agree that an interest charge of .5% per month (equaling an annual percentage rate of 6%) will be applied to my account balance if I do not pay charges within 30 days of the day on which payment is due.

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