Registration Form

Pediatric Associates

115 Norwood Park South, Suite 110, Norwood, MA 02062 

(p): 781-769-4090, Fax: 781-769-6485

122 Grove  Street, Franklin, MA 02038 

(p): 508-528-5404, Fax: 508-528-5383

Parent 1: *

Address: *

Parent 2 : *

Address *

Primary Insurance: *

Secondary Insurance (if applicable):

Child 1:

Child 2:

Child 3:

Child 4 :

Please Note: this office does not do third party billing to ex-spouses or other individuals. Whichever parent/guardian brings the child to the office is responsible for any outstanding deductibles, co-payments, co-insurances, or bills due to lapses in insurance coverage. There are no exceptions.

I authorize payment of medical benefits to the physician or supplier of PEDIATRIC ASSOCIATES OF NORWOOD AND FRANKLIN, P.C. for services rendered during my child(ren)'s examination and/or treatment. I also authorize my child(ren)'s physican to release any information acquired in the course of their examination and/or treatement to my insurance company to determine these benefits or the benefits payable for related services.

By signing below, I indicate that I have read and understand all the information on this form. Any information that I have entered is, to the best of my knowledge, correct.

I understand that the information submitted may include personal health information and consent to its secure storage and use.

Please click, "Submit to Pediatric Associates" to send electronically, or print this form and deliver it to our office.