Austin Association of Otolaryngologists

Pediatric Registration

Please correct the errors described below.

Patient Information

If yes, we will need a copy of the order for our records.

Responsible Party (Please give your insurance card to the receptionist)

In case of Emergency

Authorization: I authorize Assignment of Insurance Benefits to Melba F. Lewis, MD. I understand I am responsible for payment of services provided but not covered by insurance. I authorize release of Medical Records and other information to requesting insurance companies. I acknowledge responsibility for payment of lab services provided by outside lab services. I acknowledge responsibility for referral procedures and payments to specialist and other healthcare professionals.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Pediatric Medical History

Current and Past History

Current Illnesses and Conditions

Family Medical History

Pediatric HIPAA Acknowledgement Consent Form

I understand that under Health Insurance Portability and Accountability Act (HIPAA) of 1996, I have certain rights to privacy regarding my child's protected health information. I understand that this information can will be used to:

  • Conduct, plan and direct my treatment and follow-up care among the doctor and other designated healthcare professionals.
  • Conduct normal healthcare operations such as assessments/evaluations and certifications.
  • Assignment of payments from your insurance company.

I have been informed of the HIPAA Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information available in print. I have reviewed the HIPAA Notice of Privacy Practices and acknowledge the review. I understand that this office has the right to change the HIPAA Notice of Privacy Practices as warranted and directed by local/state/federal entities.

I understand that I may request in writing that this practice restrict how my private information is used or disclosed for treatment and payment. I understand the practice is not required to agree to any requested restrictions.

I consent to allow the following caretakers to bring my child for treatment:

Add caretaker

I understand I may revoke this consent in writing at any time.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Notice to our Patients

The scope used to examine your nose and throat is a necessary diagnostic tool which may replace the need for additional, costly diagnostic procedures such as Computed Tomography (CT scan), in some circumstances. Additionally, please consider that the information acquired using the in office scoping procedure allows thorough, same day diagnosis in most circumstances.

Please note: this procedure, like a CT scan, MAY be subject to your deductible and/or coinsurance under your health insurance plan.

For any diagnostic procedure that is performed, you may be asked to pay the insurance allowed amount for the procedure at the time of service. Our office will bill your insurance policy and apply any contractual discounts to your balance.

Late Cancellation and "No Show" Agreement

We kindly ask you to provide 24 hours notice in the event you must cancel or reschedule an appointment. Failure to cancel or reschedule appointments 24 hours in advance will incur a $60 fee.

Thank you for your advanced notice and cooperation.

Please sign below, acknowledging the above statement and consent to the "No Show" agreement.

Medical Information Release Form (HIPAA Release Form)

Release of Information
I authorize the release of information including the diagnosis, records; examination rendered to me and claims of information. This information may be released to:

This Release of Information will remain in effect until terminated by me in writing.

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