Pediatric Health Associates, P.C.

Kerry Fierstein, MD, Brian Goldstein, MD, Nancy Lippman, MD, Stewart Samuel, MD, Lori Keschner, MD, Rosemarie Read, MD
Fellows, American Academy of Pediatrics

Patient Information

Last Name	First Name, Middle Initial	Date Of Birth (mm/dd/yyyy) ,
Home Address	City, State, Zip ,	Telephone

Mother's Details

Mother's Name	Social Security No	Date of Birth (mm/dd/yyyy)
Employer	Address
Tel	Other Tel / Cellular	Email

Father's Details

Father's Name	Social Security No	Date of Birth
Employer	Address
Tel	Other Tel / Cellular	Email

Insurance Information

Insurance Carrier
Claim Address
City, State, Zip
Telephone No
Policy No.
Group No.
Policy Holder's Name
Social Security No
Date of Birth
Pharmacy
Telephone

Inurance Verification

I hereby authorise direct payment of medical benefits to Pediatric Health Associates P.C. for services rendered by the doctors or persons working under their supervision. I understand that I am financially responsible for any balance not covered by my insurance company. A photocopy of these assignments shall be as valid as the original.

Parent / Guardian's Signature

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