PCHS Demographic Form- North Kitsap

PCHS Demographic Form

PCHS will be providing Covid Testing.

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* 1. Please select the school/sport for your child:

Kingston Middle School- Boys Basketball

Kingston Middle School- Girls Basketball

Kingston Middle School- Wrestling

Kingston High School- Cheer

Kingston High School- Boys Basketball

Kingston High School- Girls Basketball

Kingston High School- Wrestling

Poulsbo Middle School- Boys Basketball

Poulsbo Middle School- Girls Basketball

Poulsbo Middle School- Wrestling

Poulsbo Middle School- Cheer

North Kitsap High School- Cheer

North Kitsap High School- Boys Basketball

North Kitsap High School- Girls Basketball

North Kitsap High School- Wrestling

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* 2. Last Name

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* 3. First Name

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* 4. Date of Birth

Date / Time

Date

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* 5. Sex at Birth

Male

Female

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* 6. Address

Address *

City/Town *

State/Province *

ZIP/Postal Code *

Email Address

Phone Number *

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* 7. Consent to Call

Yes

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* 8. Text Message ok?

Yes

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* 9. Insurance

Primary Insurance Name

ID Number

Guarantor (person who is responsible for the insurance) Name and Date of Birth

Insurance mailing address for claims

Secondary Insurance Name

ID Number

Guarantor (person who is responsible for the insurance) Name and Date of Birth

Insurance mailing address for claims

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* 10. If uninsured and you would like to be contacted about how to apply for slide scale or insurance, please check the box.

Contact me about Slide Scale or to set up an appointment with an insurance navigator

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* 11. Billing Authorization
Please read the statements below. Check each box (last box for Medicare recipients only)
Enter your name and date to provide authorization.

I accept financial responsibility for all my professional services and/or supplies. Payment for service is due at the time rendered unless arrangements have been made.

I authorize my insurance to pay PCHS directly. I am financially responsible for any balance due. I authorize PCHS or the insurance company to release any information for claims unless specifically limited by me in writing.

(Medicare Recipients Only) I request that payment for authorized Medicare benefits be made on behalf of Peninsula Community Health Services for any services provided to me

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* 12. Name

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* 13. Date

Date / Time

Date

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* 14. Select the box below if you would like to receive a copy of the Patient Rights and Responsibilities

Mail me a copy of the Rights and Responsibilities

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* 15. Select the box below to consent to Covid testing.

By selecting this box you are consenting to covid testing services rendered by Peninsula Community Health Services.

PCHS Demographic Form- North Kitsap