# Insurance Information Form

## Patient Information
- **Patient Name:** _________________________
- **Date of Birth:** _________________________
- **Relationship to Patient:** _________________________

## Primary Insurance Information
- **Insurance Company:** _________________________
- **Policy Holder Name:** _________________________
- **Policy Number:** _________________________
- **Group Number:** _________________________
- **Copay Amount:** $_________________________
- **Deductible:** $_________________________

## Secondary Insurance Information
☐ Has Secondary Insurance
- **Insurance Company:** _________________________
- **Policy Number:** _________________________
- **Group Number:** _________________________

## Employer Information
- **Primary Employer Name:** _________________________
- **Employer Address:** _________________________
- **City:** _________________________ **State:** _________ **ZIP:** _________

## Authorization & Consent
☐ I authorize Rose Pediatrics Care to bill my insurance company
☐ I authorize the release of medical information for insurance processing
☐ I authorize contact with my insurance company for verification
☐ I understand I am financially responsible for charges not covered by insurance

**Policy Holder Signature:** _________________________
**Date:** _________________________

---
*Rose Pediatrics Care - Insurance Information Form*