Print and complete this form before your child’s first visit. Bring it with you, along with photo ID for the parent or guardian, the child’s insurance card, and any current prescriptions or immunization records. Need a paper copy mailed to you? Call (518) 370-1441.
What you type stays in your browser. Hometown does not receive or store anything you fill in here. Use the Print button to print a copy with your information, then bring or fax the printed form to us.
Pediatric Patient Registration
Hometown Health Centers
Patient information
Patient Name
Address Homeless:
City
State
Zip Code
Sex
Date of Birth
For reporting purposes only
Race:
Ethnicity:
Primary Language:
Head of household / person responsible for this account
Mother / Guardian / Parent 1
Name
Mother’s Maiden Name
Address
City
State
Zip Code
Date of Birth
Relationship
Marital Status
Home Phone
Cell Phone
Work Phone
HHC can send reminders by (check for yes):
Employer
Father / Guardian / Parent 2
Name
Address
City
State
Zip Code
Date of Birth
Relationship
Marital Status
Home Phone
Cell Phone
Work Phone
HHC can send reminders by (check for yes):
Employer
Custody
Who has custody?
Are there any legal restrictions that would restrict the non-custodial parent from consenting to medical treatment for the child or from obtaining information about the child’s medical treatment?
Household information
As a Federally Qualified Health Center, we need the following information for statistical reports.
Approximate Annual Family Income
$
Number of Family Members
Emergency contact
If parents cannot be reached.
Name
Phone #
Address
Relationship
Insurance
Primary Insurance
ID #
Insurance Subscriber Name
Secondary Insurance
ID #
Insurance Subscriber Name
Pharmacy
Name of Pharmacy
Phone #
Address / Location
Release of information / assignment of benefits
I authorize Hometown Health Centers to release any information, including diagnosis and the records of any treatment or examination rendered to me (or my child) during the period of such care, to third-party payers and/or health practitioners.
I authorize and request my insurance company to pay, directly to Hometown Health Centers, group insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
I hereby certify that to the best of my knowledge all of the above information is true and correct. I understand that program officials may verify information on this form or use information for statistical analysis. I also understand that information I supply will be kept confidential.
Payment is expected at the time of service unless other arrangements have been made. We accept cash, checks, and credit cards.
Parent 1 / Guardian Signature
Date
Parent 2 / Guardian Signature
Date
Signature of HHC Staff
Date