Registration Form

Preferred Method of Contact:          CHOOSE ONE BELOW:

I authorize Pediatric Associates of Whidbey Island to deliver our cause to be delivered the following types of messages by voice call or text messaging using an automatic telephone dialing system or an artificial or pre-recorded voice to include by not limited to, appointment reminders, visit recall and seasonal services (Flu Clinic).

PATIENT PORTAL: Please ask the receptionist to enroll you in our secure portal for limited access to your child's medical records.

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Lives with patient?

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Lives with patient?

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PRIVACY PRACTICES

I acknowledge that Pediatric Associates of Whidbey Island's "Notice of Privacy Practices" has been offered to me. The notice provides detailed information about how the practice may use and disclose my confidential information. I understand that the physician has reserved the right to change his or her privacy practices that are described in the Notice. I also understand that a copy of any revised Notice will be provided to me or made available to me.

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FINANCIAL RESPONSIBILITY:

INSURANCE INFORMATION: ** Must be presented at EVERY visit.

I hereby authorized Pediatric Associates of Whidbey Island to release any medical or other information necessary in order to process insurance claims billing on my behalf. I authorize payment directly to the doctor for any benefits available under my insurance plan. I hereby assign to the physician all payments for medical services rendered. I understand that I am financially responsible for any amount not covered by my insurance. I understand that I am responsible for all fees, regardless of insurance coverage. Co-payments must be paid at the time of service.

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Permission for Medical Treatment of a Minor

I,                                                                                                              ,                                                                                          ,

Give Permission to the following to seek medical treatment for my child(ren) in my absence.

Please list first and last name of person being named.

(Parent/Guardian Name)

(Relationship to Patient)

(Relationship to patient)

*********                Initial here if you give permission for above-named person(s) to speak with any representative (i.e. nurse, physician, receptionist, etc.) of Pediatric Associates of Whidbey Island regarding above-named minor patient(s).

Signature of Parent/Guardian:                                                                           Date:

At any time you may revoke or amend this permission by notifying Pediatric Associates of Whidbey Island in writing.

275 SE Cabot Dr., Suite B-102 

Oak Harbor, WA 98277

360-675-5555

© 2020 Pediatric Associates of Whidbey Island  

1690 Layton Rd.

Freeland, WA 98249

360-331-1314