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  • PATIENT REGISTRATION FORM


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  • PARENT AND GUARDIAN INFORMATION

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  • Secondary Parent or Guardian

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  • Guarantor (person responsible for the bill)

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  • Emergency Contact Information


  • Insurance Information (Primary)

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  • Insurance Information (Secondary)

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  • Referral Information


  • Household Annual Income (required)

  • This information is necessary for Kids Center to receive support from Metro United Way and other funders. If you wish to be considered for financial assistance from Kids Center, please attach a copy of the first page of your most recent federal form 1040.


  • PATIENT FINANCIAL POLICY

    Thank you for choosing Kids Center for Pediatric Therapies as your child’s treatment service provider. We are committed to providing you with the best possible care. Your clear understanding of our financial policy is important to our agency/family relationship.

    INSURANCE CONDITIONS
    We must emphasize that, as medical care providers, our relationship is with you and not with your insurance company. We cannot accept the responsibility of negotiating the claims with insurance companies or any other persons. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date of the services rendered.

    Your insurance coverage is a contract between you and your insurance company. It is very important that you understand the provisions of your policy. We cannot guarantee payment of claims. If your insurance company pays only a portion of the bill or rejects your claim, any contact or explanation should be made to you, their policyholder. Reduction or rejection of your claim by your insurance company does not relieve you of your financial responsibility. Please remember that professional services are rendered and charged to the patient, not the insurance company.

    FINANCIAL AGREEMENTS
    I understand and agree that if any insurance company requires a referral from my primary care physician prior to receiving services at Kids Center, it is my responsibility to obtain the referral and give prior authorization numbers to Kids Center. Referrals and/or prescriptions may be faxed to Kids Center at :

    Central Campus: (502) 635‐1147
    East Campus: (502) 589‐2409

  • I authorize any payment of medical benefits to be paid directly to Kids Center. I authorize release of my medical information necessary to process my claim and secure payment.

  • I understand and agree that I am financially responsible for all charges whether or not paid by my insurance company. I agree that I am responsible for any deductibles and co‐pays are expected at time of service. I agree to keep my account current and to notify the billing department of any changes in my insurance coverage.

  • If I cannot pay my balance, I agree to work out a payment plan by contacting the Assistant Executive Director for Program Services at (502) 635‐6397.

  • PLEASE BE AWARE THAT FREQUENTLY IT TAKES SOME TIME FOR CLAIMS TO BE RECONCILED BY YOUR INSURANCE COMPANY. THIS CREATES THE POSSIBILITY THAT A LARGE PATIENT OWED BALANCE CAN ACCRUE BEFORE YOU RECEIVE YOUR STATEMENT FROM KIDS CENTER. WE ENCOURAGE YOU TO UNDERSTAND WHAT YOUR LIABILITY FOR SERVICES COULD BE ACCORDING TO YOUR SPECIFIC POLICY COVERAGE. OUR BILLING MANAGER IS AVAILABLE BY APPOINTMENT TO GO OVER THIS WITH YOU.

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