UPDOX - PATIENT PORTAL

This update sheet must be completed and signed YEARLY for insurance billing purposes.

Child Information

Name * Date of Birth * M/F * Race * Name Date of Birth M/F Race Name Date of Birth M/F Race Mailing Address * Home Phone # * Cell Phone # * Preferred Pharmacy * Child's School (if applicable) E-Mail Address: *

Parent's Information (Mother, Father, Legal Guardian)

Parent #1 Name * Employer Home Address * Home Phone # * Work Phone # Cell Phone # * DOB * SSN * Parent #2 Name * Employer Home Address * Home Phone # Work Phone # Cell Phone # * DOB * SSN *

Notify in case of Emergency ( Other than parent's )

Name * Relation * Phone number *

Insurance Information

Name of insurance company * Insurance company address Policy holder name * Policy holder: * Policy holder employer Policy # * Group # * Name of insurance company #2 insurance #2 address Policy holder name for Insurance #2 Policy holder employer for Insurance #2 Policy # for Insurance #2 Group # for insurance #2

This is a direct assignment of my rights and benefits under this policy, I agree to pay charges not paid by insurance. A photocopy of this agreement shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company , adjuster, or attorney involved in this case. I have received a copy of HIPPA (Health Insurance Portability and Privacy Act)and agree to the policy.

Name and DOB of Guardian completing form * Electronic Signature of Guarantor/Guardian * Date *