Patient Registration
Patient Name: ______________________________________________ Relationship to Guarantor: ________________________________
Date of Birth: ____________________________________Sex: M ___ F ___ Social Security Number: _________________________________
Home Address: _______________________________________________________________________________________________________
City: ________________________________________________________ State: _______________ Zip Code: __________________________
Home Telephone: ( )____________________________________________ Referred By: ____________________________________________
E-MAIL ADDRESS:__________________________________________________________________
Siblings:
Name
Sex
DOB
SS#
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Father’s Name: ___________________________________________________________ Date of Birth: ____________________________
Home Address (if different): _____________________________________________________________________________________________
City: _______________________________________________________ State: _______________ Zip Code: ___________________________
Home Telephone: (
)_____________________ Work Telephone: (
)___________________ Cell Phone: (
)____________________
Employer: __________________________________________ Driver’s License: ________________________________________________
Social Security Number: _______________________________ Marital Status: ____________________________________________________
Mother’s Name: ________________________________________________________ Date of Birth: _____________________________
Home Address (if different): ____________________________________________________________________________________________
City: ______________________________________________________ State: _______________ Zip Code: ___________________________
Home Telephone: (
)__________________ Work Telephone: (
)_____________________ Cell Phone: (
Employer: __________________________________________ Driver’s License:
)_______________________
_______________________________________________
Social Security Number: _______________________________ Marital Status: ___________________________________________________
INSURANCE INFORMATION
Primary Insurance Name: _______________________________________________ Effective Date: _________________________________
Address: __________________________________________________________________________________________________________
City: ________________________________________________ State: _____________ Zip Code: __________________________________
Telephone Number: ___________________________ ID Number: _____________________________ Group Number: _________________
Full Name of Insured: ________________________________________ Policy Type: __HMO __PPO __PPC __Other: __________________
If you belong to an HMO, do you also have other Group Insurance Coverage? ______ Yes _____ No
Co-Pay Amount: ______________________________
How did you hear about us? ________________________________Previous Physician______________________________________________
*****************************************PLEASE READ & SIGN NEXT PAGE******************************************
Sunshine Pediatrics of Central Florida, PL © 2007
NOTIFY IN CASE OF EMERGENCY!!
Name: ________________________________________________ Relationship: _______________________ Phone: (
)_________________
Name: ________________________________________________ Relationship: _______________________ Phone: (
)_________________
OFFICE FINANCIAL AGREEMENT: AUTHORIZATION OF ASSIGNMENT OF INSURANCE BENEFITS
& RELEASE OF MEDICAL RECORDS
*Please initial after each statement that you understand and agree with our policies*
I understand payment of all medical care is due at the time of service. In case of divorced parents, responsibility and payment shall be that of the
guardian bringing the child in for treatment. I understand that it is my responsibility to pay any deductible, co-insurance, or any other balance not
paid by my insurance company. I understand that if my account is not paid in full by my insurance within 60 days of the date of service, I am
responsible for payment in full. I understand a late fee of $5.00 per month will be applied to balances once they become 60 days overdue. I
understand that, in case of default, I am responsible for any costs incurred in the collection of patient account, currently 30% of the balance, as well
as reasonable attorney fees and court costs. (Initial ______ )
We do not bill secondary insurances. In the event you have two insurances, we are happy to provide you with any documentation necessary for you to submit
information to your secondary insurance. (Initial_______)
There is a $5 billing fee when co-pay is not paid on date of visit. Your insurance requires you to pay your co-pay at every visit and we incur an
expense in billing for these small balances. Therefore, we find it necessary to charge this fee. (Initial ______ )
There is also a $35 returned check fee for any checks returned unpaid through Sunshine Pediatrics’ bank. (Initial ______ )
Missed appointments: Sunshine Pediatrics requires 24-hour advance notice for all cancellations. Failure to notify our office will result in a $35.00
fee. Emergencies will be considered on a case-by-case basis for waiver of this fee. (Initial ______ )
Walk-ins: There is a $35 walk-in fee for anyone bringing their child to be seen without previously scheduling an appointment. This fee will be
collected at check-in prior to the patient being seen. (Initial ______ )
As a courtesy, we ask that you contact our office immediately if you are going to be late to your appointment. If you arrive 15 minutes or
later, your appointment will be rescheduled.
Newborns (Initial below if applicable)
*Payment will be collected at time of service for all newborn visits until we are able to verify their eligibility on your insurance
plan. Once we verify coverage, we will then bill all claims to insurance and you will be reimbursed for payments made over and
above any co pay, coinsurance and deductible amounts. (Initial ______ ).

Sunshine Pediatrics only bills ONE insurance policy. If you add your baby to two policies, we will only bill the primary
insurance (which falls under the birthday rule: whomever’s birthday is first in the year is considered the guarantor of the
PRIMARY insurance). (Initial ____ )

Circumcisions are an elective procedure. Therefore, we require payment for this procedure at the time of service. It will then
be submitted to your insurance once baby is active. If we receive payment from the insurance company, you will promptly
be reimbursed. (Initial _____ )
I hereby grant permission to Sunshine Pediatrics to release any pertinent information to my insurance company upon request, and I also authorize
payment directly to Sunshine Pediatrics. A photo static copy of this authorization shall be considered as effective and valid as the original.
Signature: _________________________________________________ Date: ___________________ Witness: __________________________
Sunshine Pediatrics of Central Florida, PL © 2007
Sunshine Pediatrics
of Central Florida, Inc.
210 Lookout Place
Maitland, Fl. 32751
I hereby acknowledge that I have been informed of Sunshine Pediatrics’ Notice of Privacy Practices, which is
posted in our lobby and in each exam room. I also will be given a copy of this document upon request.
Sunshine Pediatrics may discuss information regarding my child’s treatment and care with the following
individuals (other than parent). This could be in person, by telephone, fax, or by mail and includes the following
information. If no one, please indicate “ no one.”
______________________________
Name
_______________________________
Relationship
______________________________
Name
_______________________________
Relationship
______________________________
Name
_______________________________
Relationship
Please initial each of the following you are authorizing:
___General Medical Information
___Financial Information
___Psychiatric Information
___Drug/Alcohol Abuse
___Labs/Diagnostic Testing
The above information may be sent to another doctor’s office, hospital, lab etc. for continuing treatment, such
as necessary for referrals to a specialist, testing or lab work etc. and does not require additional authorization
from the parent.
_____________________________________
Patient Name
_____________________________________
Signature of Parent or Legal Guardian
_____________________________________
Date
Sunshine Pediatrics of Central Florida, PL © 2007