test new child form

PARENTS' EDUCATION: (Enter last grade completed.)

EMPLOYMENT  STATUS

PATIENT PHYSICAL HEALTH RECORD (To be completed by parent / guardian)

6) Has child or mother had any of the following at birth: (Please check one for each condition.)

Any time after the first fourteen days of life, did your child have the following: (Please Check One.)

INFECTIONS :

7) Do you have a regular pediatrician?

8) Vaccination Records:

11) Has anyone in the family ever had the following?

MONTHLY BUDGET

If you will not be using insurance, please complete the below Monthly Budget Information:

I hereby assign the insurance benefits to which I may be entitled to the Karen Horney Clinic, Inc. and I authorize payment of these to be made directly to said clinic. I authorize the Karen Horney Clinic, Inc. to communicate any pertinent data to my insurance company regarding this assignment. I also understand that if for any reason my insurance does not cover my expenses that I will be held responsible for prompt payment of any monies due:

FAMILY INFORMATION

MONTHLY HOUSEHOLD & LIVING EXPENSES

  INSURANCE BENEFITS INFORMATION & PATIENT RESPONSIBILITIES

*****PLEASE MAKE SURE THE BELOW INFORMATION IS COMPLETE & SIGNED*****

I hereby assign the insurance benefits to which I may be entitled to the Karen Horney Clinic, Inc. and I authorize payment of these to be made directly to said clinic. I authorize the Karen Horney Clinic, Inc. to communicate any pertinent data to my insurance company regarding this assignment. I also understand that if for any reason my insurance does not cover my expenses that I will be held responsible for prompt payment of any monies due:

In-Network Insurances Please be prepared to pay before each appointment. You are responsible for any deductible, copay and/or coinsurance indicated by your insurance plan, including the full balance due to termination of coverage. You will be responsible for “non-covered” services as deemed by your carriers. NOTE: Some insurance carriers may require that you notify them of your visit with us. Please contact them to avoid additional financial responsibility. 

Out-of-Network Insurances Please be prepared to pay before each appointment. You are responsible for 100% of the fee.

Click or drag files to this area to upload. You can upload up to 4 files.
Upload a scan of your Insurance cards, both front and back.