If you have any questions concerning the completion of this form, please call 305-663-8413.

Bold fields are required.

Date of Admission/Diagnostic Testing	(mm/dd/yyyy)
Has the patient ever received services at any Miami Children's Hospital Location?	YesNo
Type of Procedure/Treatment/Test	Radiology Pulmonology Nephrology Hematology/Oncology Immunology Plastic Surgery Neurology Laboratory Cardiology Orthopedic Rehabilitation Services Ambulatory Surgery In-Patient Surgery Other
Patient's Last Name
Patient's First Name
Patient's Middle Initial
Birth Date	(mm/dd/yyyy)
Sex	MaleFemale
City, State or Country of Birth
Religion Preference
Phone Number
Patient Email
Patient Address
City
State	Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Islands Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
Zip Code
Referring Physician (Physician ordering Services)
Primary Care Physician (PCP)
PARENT INFORMATION
Father's Name If applicable
Birth Date	(mm/dd/yyyy)
Phone Number
Employer
Is the father's address the same as the patient's address?	Yes No
Mother's Name
Birth Date	(mm/dd/yyyy)
Phone Number
Employer
Is the mother's address the same as the patient's address?	Yes No
MEDICAID / MEDICARE
Does the patient Have Medicaid/Medicare?	Yes No
PRIMARY HEALTH INSURANCE INFORMATION
Does the patient Have Health Insurance?	Yes No
SECONDARY HEALTH INSURANCE Any other medical insurance plan that may provide additional coverage.
Does the patient Have Secondary Health Insurance?	Yes No
Parent/patient (18 years or over) or Legal Guardian must be present to sign required documents. On your Admission/Registration day, please bring your prescription, Health Insurance card, other Insurance cards and your Credit Card you may be required to pay a deductible, co-pay, payment or deposit if applicable. Deposits/Co-payments: Deposits/CO-payments are determined by your insurance company and based on specific plan benefits. For most services, the co-payment will be listed on your insurance card. CO-payments/Patients portions are due at the time of service.