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- Jan 19, 2019 · You can look up a patient in several ways: by full name and date of birth, by social security number, and by driver license number. No matter which method you use to look up a patient, the Address , DOB , SSN , and Phone fields may automatically populate.
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Authorization to Release Information and Assignment of Benefits . I hereby authorize the release of medical information necessary to file a claim with my health insurance company, and I authorize the assignment of benefits , otherwise payable to me. to Kids First Pediatrics of Georgia. I understand that I am financially responsible for payment for Print policy owner name: SSN: DOB: ____ /____ / _____ Telephone: Email: Address: City: State: ZIP: Special Notice for Residents of a Community Property State: A spouse or former spouse may have an interest in life insurance proceeds or any accumulated cash value if the policy premiums were paid with community funds.
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