Party Responsible for Payment of Medical Services:
Who referred you to our office?
How did you hear about our practice?
Primary Insurance Company::
Name of Insured:
Date of Birth:
Authorization of Treatment and Assignment of Benefit
I authorize Dr. Martha Sharkey to treat my child. I further authorize the release of medical information necessary for the completion of insurance forms. I authorize payment directly to Rainbow Pediatric Clinic, PA or Martha Ann B. Sharkey, MD for all medical or surgical benefits otherwise payable to me under the terms of my insurance. I understand that I am financially responsible for all co-payments and any charges not paid by my insurance. A photocopy of this authorization shall be considered as effective as valid as the original. Medical care or immunizations cannot be given unless my child is accompanied by one of the following:
I understand that if my child's physician, or any person employed by or under the direction and control of my child's physician(s), is directly exposed to my child's body fluids in any manner which may, according to the then current guidelines for the Center for Disease Control, transmit the human immunodeficiency virus (HIV) or hepatitis B or C viruses, that I am deemed by law to have consented to testing for infection with HIV or hepatitis B or C viruses. I further understand that by law I will have deemed to have consented to the release of these test results to the person who is exposed to my child's body fluids.
Parent/Guardian's Electronic signature:
Please complete the following so that we may contact you properly and securely:
Please list the family members or other persons, if any, whom we may inform about your child's general medical condition and diagnoeses (including treatment, payment and health care operations).
Please list the family members or significant others, if any, whom we may inform about your childs's medical conditions ONLY IN AN EMERGENCY
Please print the address of where you would like your billing statments and / or correspondence from our office to be sent if other than your home.
Please print the telephone number where you want to recieve calls about your appointments, lab and X-ray results, or other health care information if other than your home telephone number.
*Please be aware that a cell phone is not a secure and private line
Can confidential messages (i.e., appointment reminders) be left on your telephone answering machine or voicemail?
Please fill in all of the fields below.
Remember to click on the submit button at the bottom. Thank you!