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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

Parent/Other Caretaker Information

Parent/Other Caretaker Name
Click Here If The Parent/Other Caretaker Address Is Not The Same As The Child's Address, If So, Enter It Below

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

Is The Primary Insured Address The Same As The Child's Address? If Not, Enter It Below
Primary Insured Sex
Is There A Secondary Health Plan?

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)