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1 Daniel Burnham Court #330C, San Francisco, CA 94109 (415)668-0888

1 Daniel Burnham Court #330C, San Francisco, CA 94109 (415)668-0888-2025

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4.4 out of 5

28 votes

The document is a comprehensive patient intake form for Golden Gate Pediatrics, detailing personal, medical, and insurance information required for pediatric care. It includes sections for child and parent details, medical history, developmental concerns, and consent for the use of health information. Additionally, it outlines office policies regarding insurance claims, appointment cancellations, and vaccination requirements. The document emphasizes the importance of privacy practices in compliance with HIPAA regulations.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the child's name and birthdate in the designated fields. Ensure accuracy as this information is crucial for medical records.
Select the gender of the child by checking the appropriate box. This helps in maintaining accurate health records.
Fill out the parent or guardian's details, including names, contact information, and relationship to the patient. This section is vital for communication regarding your child's health.
Complete the insurance claim submission section thoroughly. Missing information could lead to non-payment from your insurance plan.
Review all sections carefully before submitting. Use our platform’s features to save your progress and make edits as needed.

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Versions	Form popularity	Fillable & printable
2020	4.4 Satisfied (28 Votes)

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