If you have any questions concerning the completion of this form, please call 305-663-8413.
Has the patient ever received services at any Nicklaus Children's Hospital Location?:
Type of Procedure / Treatment / Test
Please select the applicable category below, then select procedure/treatment/test.
Is the mother's address the same as the patient's address?:
Is the father's address the same as the patient's address?:
Does the patient have Medicaid/Medicare?:
Does the patient have Health Insurance?:
Does the patient have Secondary Health Insurance that may provide additional coverage?:
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.