FAITH

Pediatrics & Adolescent Medicine

Where Children are our Passion...

Spanish  Speaking Provider

Se habla espanol

New Patient Forms

 

Please print and complete forms and bring them with you to your appointment. You may also fillout these forms online and submit them.

 

CLICK HERE FOR REGISTRATION FORM

CLICK HERE FOR FINANCIAL FORM

 

We ask that new patients email us your insurance information so that we may verify insurance before your appointment to help ensure there are no delays at time of appointment. Please email to medicalrecords@faithpediatrics.com

 

Faith Pediatrics and Adolescent Medicine

Registration Information

 

 

Today’s Date: ______________

 

Patient Information

 

First name: ________________ MI: ______ Last name: ______________________

 

Birth date:___/___/___   Age:____ Sex: ____ Social Security:_____-____-______

 

Street Address:_____________________ Home Phone no.:(     )_______________

 

City:_________________________ State:_____________ ZIP Code:___________

 

How Long have you lived at this address:_____ Email Address:_________________

 

Parent Information

 

Mother’s last name:_____________ First name:_____________ MI:____

 

Birthdate:___/___/____

 

Social Security Number:_____-____-_____ Address:(if different) ________________

 

Father’s Last name:______________ First name:_____________ MI:____

 

Birthdate: ___/___/____

 

Social Security Number: _____-___-______ Address: (if different) ________________

 

Insurance Information

 

Primary Insurance:( please check one) Medicaid__ BCBS__ Cigna__ Aetna ___

 

United Heathcare __ Tricare__ MedCost ___ PCHS__ BCBS Health Choice___ Other__

 

Group Number #____________ Policy Number#___________ Co-Pay________

 

Secondary Insurance: ( please check one) Medicaid__ BCBS___ Cigna__ Aetna___

 

 United Heathcare ___Tricare___ MedCost___ PCHS__ BCBS Health Choice__Other__

 

 

In Case Of Emergency

 

Name of local friend or relative (not living at same address) ________________________

Relationship to patient: ___________ Home phone no :(      )____________________

 

 

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Faith Pediatrics. I understand that I am financially responsible for any balance. I also authorize Faith Pediatrics or insurance company to release any information required to process my claims.

 

Patient/Guardian signature: ______________________ Date: _________________

 

 

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FAITH PEDIATRICS

Connell Covington, MD

Valerie Rinehammer, PNP

HOUR OF OPERATION

 

Monday 8:30am - 5:30pm

Tuesday  8:30am - 5:30pm

Wednesday 8:30am - 1:30pm

Thursday 8:30 -5:30pm

Friday 8:30am - 5:30pm

Saturday & Sunday - Closed

(Coming Soon Saturday & Sunday by Appt.)

Closed for Lunch Daily 1:30pm - 2:30pm

 

MORE INFORMATION

 

 

 

 

 

FAITH PEDIATRICS & ADOLESCENT MEDICINE