RUB PEDIATRICS MD PA 21110 Biscayne Blvd, Suite 308 Aventura, FL 33180 (305) 932-1007 1190 NW 95th Street, Suite 409 Miami, FL 33150 (305) 696-9490

WELCOME BIENVENIDOS Patient Information Sheet

Thank you for your patience in filling out this form so that we can better serve you. (Gracias por su paciencia en llenar este formulario, el cual nos ayudará a servirle major)

LEGAL NAME OF CHILD: TODAY’S DATE: (nombre de su hijo(a): (fecha) DATE OF BIRTH: CHILD’S SOCIAL SECURITY #: ___________________ (fecha de nacimiento) (número de su hijo(a) de social security) MOTHER’S NAME (nombre de la madre): FATHER’S NAME (nombre del padre): Parent’s Personal Information: Single (soltero) Married (casado) Divorced (divorcio) Preferred Language: English Spanish Creole Other ____________ Referring Doctor/Friend (médico o amigo que lo refiere): Local person to notify in case of emergency, if unable to reach parents (la persona mas cercana en caso de emergencia): Name of local person: _______________________________________ Phone (télefono): __________________________ I attest that the information provided above is true and correct and I understand that falsifying information is illegal and punishable to the fullest extent of the law. Signature of Parent/Legal Guardian: ___________________________________________ Date: _______________________

MOTHER’S INFORMATION (información de la madre):

HOME ADDRESS (dirección): CITY/STATE/ZIP (ciudad/estado): HOME PHONE (télefono de la casa): CELLULAR PHONE (télefono celular): WORK PHONE (télefono del trabajo): EMAIL: OCCUPATION (ocupación): DRIVER’S LICENSE # (número de licencia): SOCIAL SECURITY # (número de social security): DATE OF BIRTH: (fecha de nacimiento de la madre):

FATHER’S INFORMATION (información del padre):

HOME ADDRESS (dirección): CITY/STATE/ZIP (ciudad/estado): HOME PHONE (télefono de la casa): CELLULAR PHONE (télefono celular): WORK PHONE (télefono del trabajo): EMAIL: OCCUPATION (ocupación): DRIVER’S LICENSE # (número de licencia): SOCIAL SECURITY # (número de social security): DATE OF BIRTH: (fecha de nacimiento del padre)

Credit Card Pre-Authorization

I, ____________________________________, authorize Rub Pediatrics MD PA to keep my signature and credit card/debit card on

file to charge copayments, deductibles and coinsurances for services provided to my child,_________________________________. I agree that:

‐ This authorization is valid until cancelled in writing, sent certified, to Rub Pediatrics MD PA, 21110 Biscayne Blvd, Suite 308, Aventura, FL 33180.

‐ I will be charged the stated amount on the Explanation of Benefits (EOB) sent from my health insurance to Rub Pediatrics MD PA explaining what fees I owe. This will be charged within 7 calendar days of receiving the EOB.

‐ If health insurance benefits are assigned to Rub Pediatrics MD PA, I am responsible for the total charges incurred regardless of any insurance denial or partial payments unless other arrangements regarding fees have been made.

‐ If I have any problems or questions regarding charges made to my credit/debit card on file, I will contact the billing office at Rub Pediatrics MD PA at (305) 696-9490. I agree that I will NOT dispute any charges with my credit card company unless I have first attempted to rectify the situation with Rub Pediatrics MD PA.

‐ I further agree that if I dispute a charge with my credit/debit card, Rub Pediatrics MD PA may disclose information about my child’s visit to my credit/debit card company.

‐ I agree to update Rub Pediatrics MD PA with my new credit/debit card number if it has changed.

I have read and agreed to the above statements. SIGNATURE: ____________________________________________________

CARDHOLDER NAME: CCID:

CREDIT CARD NUMBER: EXPIRATION DATE:

CARDHOLDER BILLING ADDRESS:

CITY, STATE, ZIP:

CARDHOLDER SIGNATURE:

Primary Insurance Responsible party (persona responsable de seguro primario):

INSURANCE ID# (numero de seguro) GROUP # (numero de grupo) NAME (nombre): HOME ADDRESS (dirección): CITY/STATE/ZIP (ciudad/estado): HOME PHONE (télefono de la casa): CELLULAR PHONE (télefono celular): WORK PHONE (télefono del trabajo): EMPLOYMENT ADDRESS (dirección de su trabajo): OCCUPATION (ocupación): DRIVER’S LICENSE # (número de licencia): SOCIAL SECURITY # (número de social security): DATE OF BIRTH: (fecha de nacimiento):

Financially Responsible Party (persona responsable financieramente):

NAME (nombre): ADDRESS (dirección): CITY/STATE/ZIP (ciudad/estado): HOME PHONE (télefono de la casa): CELLULAR PHONE (télefono celular): WORK PHONE (télefono del trabajo): EMAIL: OCCUPATION (ocupación): DRIVER’S LICENSE # (número de licencia): SOCIAL SECURITY # (número de social security): DATE OF BIRTH: (fecha de nacimiento)