CASA ALEGRE PEDIATRICS
Joanne M. Ray, D.O., F.A.A.P. ▪ Cynthia R. Settles, M.D., F.A.A.P. ▪Jana G. Williams, M.D., F.A.A.P.
4181 Camino Coyote, Las Cruces, NM 88011
PATIENT INFORMATION TODAY’S DATE______________________
Patient’s Name______________________________________________Birth Date__________________Sex____________
Social Security Number________________________Phone #____________________Cell #_________________________
Physical Address_____________________________________________________________________________________ City State ZIip
Mailing Address ______________________________________________________________________________________
City State Zip
Father’s Name___________________________Mother’s Name___________________________ (____________________)
(Maiden Name)
Names and Birth Dates of Brothers and Sisters:
1______________________DOB________2____________________DOB___________3________________DOB___________ 4______________________DOB________5____________________DOB___________6________________DOB___________
EMERGENCY CONTACTS :(Other Than Parents of Patient)
Name_________________________________________________Relationship to Patient___________________________ Address____________________________________City______________________State_______Phone_______________
Other Emergency Contact: Name____________________________________________________Phone_______________
PARENT’S EMPLOYMENT INFORMATION:
Father’s Employer_________________________________Phone________________Soc Sec #______________________
Mother’s Employer________________________________ Phone________________Soc Sec #______________________
PRIMARY INSURANCE CARRIER:
Company____________________________________________Address_________________________________________
Member #____________________________________________Group __________________________________________
SECONDARY INSURANCE CARRIER:
Company____________________________________________Address_________________________________________
Member #___________________________________________ Group ___________________________________________
AUTHORIZATION OF BENEFITS AND RELEASE OF INFORMATION
I authorize the release of any medical information necessary for treatment, health care operations and to process my insurance claims. I authorize and request payment of medical benefits directly to my physician. I agree that this authorization will cover all medical services until such authorization is revoked by me. I agree that a photocopy of this form may be used in place of the original.
________________________________________________________________________________________________________________________________Signature of Responsible Party Date Relationship to Patient
AUTHORIZATION FOR EMERGENCY TREATMENT
In the event that my child should require medical care or treatment and my spouse and I should be unavailable or out of town, I give my permission for care of my child as deemed necessary.
____________________________________________________________________________________________________
Signature Date Relationship to Patient
AUTHORIZATION FOR RELEASE OF RECORDS
I hereby authorize the release of any and all medical records to the patient’s parent/guardian.
____________________________________________________________________________________________________
Signature Date Relationship to Patient
UPDATES:
INITIAL____________DATE____________ INITIAL____________DATE____________ INITIAL___________DATE___________