New Patient Information

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Jessica Chambers
5 years ago
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NEUROSURGERY DEPARTMENT AT CHILDREN S HOSPITAL New Patient Information For this initial appointment, you will need to bring: 1. Your child s radiology studies (X-rays, CT or MRI scans, etc.

1 NEUROSURGERY DEPARTMENT AT CHILDREN S HOSPITAL New Patient Information For this initial appointment, you will need to bring: 1. Your child s radiology studies (X-rays, CT or MRI scans, etc.) if they were NOT performed at Children s Hospital. These may be on a CD or on film, NOT just the paper report. 2. The referring physician s/pediatrician s office notes (unless previously faxed to our office). 3. Your child s insurance card. 4. Your completed New Patient Questionnaire (enclosed) 5. Your completed Registration form (enclosed) Please present all paperwork to our clinic registration desk when you arrive. All of the enclosed forms will need to be completed prior to your child being seen. You can also fax them to (504) prior to your visit. Our locations: Children s Hospital Main Campus 200 Henry Clay Avenue New Orleans, LA Children's Hospital Baton Rouge Clinic 720 Connells Park Lane Baton Rouge, LA Children's Hospital Burdin Riehl Clinic 1211 Coolidge Blvd., 2nd Floor Lafayette, LA Northlake Pediatrics Clinic 728 West 11th Street Covington, LA We understand that a neurosurgical problem can be stressful for patients and their families. If you need any assistance or need to reschedule, please contact our office at (504) Thank you for allowing us to participate in your child s care. The Neurosurgery Team at Children s Hospital

2 Patient's Information PLEASE PRINT MUST BE LEGAL BIRTH NAME THIS INFORMATION IS REQUIRED Last Name Suffix First Name Middle Date of Birth P.O. Box (if applicable) City State Zip Code Home Phone ( ) Cell Phone ( ) Social Security # Preferred language Sex: Male Female OPTIONAL: PLEASE SELECT ONE FROM THE FOLLOWING Religion: Ethnicity: Hispanic / Latino Not Hispanic / Latino Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian / Other Pacific Islander White Father's Information PLEASE PRINT MUST BE LEGAL BIRTH NAME THIS INFORMATION IS REQUIRED Last Name Suffix First Name Middle Home Phone ( ) Cell Phone ( ) address Social Security # Date of Birth Single Married Divorced Separated Widowed Occupation Employer Work Address Work Phone ( ) Mother's Information PLEASE PRINT MUST BE LEGAL BIRTH NAME THIS INFORMATION IS REQUIRED Last Name First Name Middle City State Zip Code Home Phone ( ) Cell Phone ( ) address Social Security # Date of Birth Single Married Divorced Separated Widowed Occupation Employer Work Address Work Phone ( ) PAC/REGISTR (05/15) Revised Bond [PDF] Registration Form 200 Henry Clay Avenue New Orleans, LA (504) ADMISSION FORMS Registration Documents HAS THE PATIENT RECEIVED SERVICES AT CHILDREN'S HOSPITAL OR ANY OF OUR CLINICS? YES NO Person Responsible for Bill PLEASE PRINT MUST BE LEGAL BIRTH NAME THIS INFORMATION IS REQUIRED Name Relationship to Child Phone Employer Address Social Security No. Emergency Contact (Other than Parent) PLEASE LIST THE NAME OF A RELATIVE OR FRIEND THAT DOES NOT LIVE WITH YOU AND CAN BE CONTACTED IN CASE OF AN EMERGENCY. Name Relationship to Patient City State Zip Code Phone: ( ) Insurance Information Name of Insured Insured Date of Birth: Insured Social Security #: FIRST POLICY: Insurance Company Phone # to verify Insurance coverage ( ) Policy # Does your insurance need to be pre-certified? Yes No SECOND POLICY: Insurance Company Phone # to verify Insurance coverage ( ) Policy # Does your insurance need to be pre-certified? Yes No Name of Insured Medicaid/CCN Bayou Plan Medicaid # Parish/County State Name of Worker Referral Information Child's Pediatrician Who referred the patient to Children's Hospital: Physician's Name Health Facility's Name Parent/Guardian/Caregiver's Signature X Date MM/DD/YY / / Time 00:00 AM/PM : OFFICE USE ONLY Medical Rec. # Acct. Physician Service Date Time *AF0040* *AF0040*

WELCOME TO OUR OFFICE PLEASE PRINT THE FOLLOWING INFORMATION THANK YOU

DATE: / / WELCOME TO OUR OFFICE PLEASE PRINT THE FOLLOWING INFORMATION THANK YOU Richard L. Corbin, DPM, FACFAS PATIENT NAME: LAST FIRST MIDDLE SOCIAL SECURITY NUMBER: / / D.O.B: / / STREET ADDRESS: CITY: