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Vaccine-Optional Pediatric Care
Pediatric Asthma
Electronic Monitoring For SIDS Prevention
Schedule An Appointment
Medical Freedom
About
BayCare
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Navigation Menu
Home
Vaccine-Optional Pediatric Care
Pediatric Asthma
Electronic Monitoring For SIDS Prevention
Schedule An Appointment
Medical Freedom
About
Please Provide Your Payment Information Here. BayCare Requires Payment Before Or At The TIme Of Your Appointment. As A Courtesy, BayCare Will File A Claim With Your Health Insurance Plan, Which Will Reimburse You Directly
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BayCare Demographic And Financial Information Form-Please Enter The Following Information
Child's Information
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Child's First Name
*
Child's Last Name
Child's Street Address
*
Child's City
*
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Child's State
*
Child's Zipcode
*
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Child's Date Of Birth
*
Child's Sex
*
Female
Male
Parent/Other Caretaker Information
Parent/Other Caretaker Name
*
First
Last
Parent/Other Caretaker Relationship
*
Parent
Grandparent
Adult Sibling
Other
Click Here If The Parent/Other Caretaker Address Is Not The Same As The Child's Address, If So, Enter It Below
Not the same
Parent/Other Caretaker Street Address
*
Parent/Other Caretaker City
*
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Parent/Other Caretaker State
*
Parent/Other Caretaker Zipcode
*
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Parent/Other Caretaker Phone
Parent/Other Caretaker Email
Health Plan Information. When There Is More Than One Health Plan That Covers The Child, The Primary Health Plan Is The Plan In The Name Of The Person With The Earlier Birth Month And Date Within That Birth Month
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Primary Insured First Name
Primary Insured Last Name
Primary Insured Date Of Birth
*
Is The Primary Insured Address The Same As The Child's Address? If Not, Enter It Below
Same
Not the same
Primary Insured Street Address
*
Primary Insured City
*
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Primary Insured State
*
Primary Insured Zipcode
*
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Primary Insured Phone
*
Primary Insured Email
*
Primary Insured Sex
Female
Male
Primary Health Plan Name
*
Enter Health Plan Name Here
Aetna
Anthem Blue Cross
Blue Shield of California
Cigna
Medicare (BayCare is not a Medicare Participating Provider)
United Health Care
Other (List below)
Other Primary Health Plan Name
Primary Insured's Health Plan Policy Number
Relationship Of Child To The Primary Insured
Child
Self
Spouse
Other
Is There A Secondary Health Plan?
No
Yes
Secondary Insured's Name
*
First
Last
Secondary Insured's Date Of Birth
*
Secondary Health Plan Name
*
Enter Health Plan Name Here
Aetna
Anthem Blue Cross
Blue Shield of California
Cigna
Medicare (BayCare is not a Medicare Participating Provider)
United Health Care
Other (List below)
Other Secondary Health Plan Name
*
Secondary Insured's Health Plan Policy Number
*
Comments
Payment: For In-Office Services, You May Pay At The Time Of Service, Cash, Check, Or Credit/Debit Card. For Out-Of-Office Services You Must Have A Payment Source On File.
Credit/Debit Card Information (Optional If You Prefer To Pay Out-Of-Pocket Amounts By Cash Or Check At The Time Of Service)
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Credit/Debit Card Number
Exp. Date (mm/yy)
CVV Number
Submit