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Hamilton County Pre-Registration Demographic Form My child has the following insurance status: This section MUST be completed or it will delay the registration process. □ Medicaid- Child 0 thru 18 years of age that has any form of Medicaid insurance. Medicaid recipients must show their card at each visit and any additional insurance cards. □ Native American or Alaskan Native - Child 0 thru 18 years of age, who identifies as an American Indian or Alaskan Native regardless of insurance. □ No Health Insurance (“Uninsured”) - Child 0 thru 18 years of age who does not have health insurance.** □ Insurance Does Not Cover Vaccines (“Underinsured”) - Child 0 thru 18 years of age who has health insurance, but the health insurance does not pay for vaccine coverage, children whose insurance covers only selected vaccines (these children are categorized as underinsured for non-covered vaccines only) or children whose insurance caps vaccine coverage at a certain amount (once that coverage amount is met, these children are categorized as “Underinsured”). Provide insurance card for verification. □ Fully Insured - Child 0 thru 18 years of age who has health insurance which provides coverage for vaccines, including those who have high deductibles, 80/20 or percentage based coverage or has a co-pay. If you do not know if your insurance covers vaccines, you need to contact them to find out. Insurance information must be submitted prior to visit to check eligibility. Our office administers all age appropriate vaccines your child is eligible for at time of visit. Date form completed: Please complete all boxes and print legibly with your child’s information: Last Name: First Name: Full Middle Name: Date of Birth: Age: Birth State: Birth Country: (ex: USA) Medicaid Gender: □ Male □ Female Race: □ White □ African American □ Asian □ Multi-racial □ Other □ Native Hawaiian/Pacific Islander □ American Indian/Alaskan Native Hispanic Descent or Ancestry: □ Hispanic □ Non-Hispanic □ Unknown Physician Name: School District Reside In: Mother Last Name: Mother First Name: Mother Maiden Name: Father Last Name: Father First Name: Mailing Address where child resides: □ Mother □ Father □ Both □ Other (specify) Address: Home Phone: Work Phone: (Direct) Cell Phone: City: State: Zip: Email Address: Name of insurance company: Policy Group Insured’s Name and Birthdate: Fax completed pre-registration form, complete immunization record and copy of both sides of insurance card to (317) 776-8506. You may also drop forms off at our office. After the record is reviewed, you will receive either a phone call or email from a nurse informing you when your child can be seen at an immunization clinic. Please do not come prior to receiving this notification. This process usually takes one week. Medicaid recipients and anyone with any other type of insurance MUST show their card at each visit to verify eligibility. ***There is an $8.00 administration fee per vaccine for Uninsured or Underinsured individuals. We accept cash or credit/debit cards with a small transaction fee. Updated 3/22/2018