A to Z Pediatrics

Patient Name:

D.O.B:

Age:

Sex:

Patient SS#:

E-Mail Address:

Home Address:

City:

State:

Zip Code:

Telephone #: (home)

(Cell):

Father’s Name:

SS#:

Place of Employment:

Phone#:

Mother’s Name:

Maiden Name:

SS#:

Place of Employment:

Phone#:

Emergency contact #:

Name:

Relationship:

Pharmacy Name:

Phone#:

Location:

Other Children:

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Please List Any Other Information You Feel Would Be Helpful To Us:

Please List Anyone In Which You Authorize To Make Medical Decisions And To Bring Your Child To Our Office In The Event That You Are Unavailable:

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Insurance Information

Responsible Party Name:

D.O.B:

Relationship to Patient:

Insured’s SS#:

Insurance Company Name:

Insurance I.D Number:

Group#:

Insurance Address:

City:

Zip:

Insured’s Place of Employment:

Please Read Carefully

I acknowledge full responsibility for the payment of the services rendered to me, and agree to pay for them in full at the time of service. (Co-payments & Deductibles are due at the time of service. Co-payments must be paid before seeing one of our providers.)

I understand and agree that health insurance policies are an arrangement between an Insurance Carrier and Myself. If a claim is denied because you have not provided correct information, the charges will be transferred to your responsibility. You are financially responsible for charges deemed by the insurance company to be billable to the patient. You must be familiar with your particular coverage and any requirements for pre-authorization, deductibles, and limitations on well child visits, immunizations, and other procedures. I understand and agree it is my responsibility to pay any deductible amount, coinsurance, or any other deductible amount, or any other balance not paid for by my insurance.

When charges are filed with your insurance carrier and assignment of insurance benefits is accepted by our office, if the fees are not paid by the insurance company within 60 days, all fees become the patient’s responsibility. Patient balances are due from you upon receipt of the statement. A $25.00 per month late charge is assessed on all delinquent patient balances. There is also a fee of $30.00 for any returned checks.

A photocopy of this signature is as valid as an original. I also authorize the physician to release all information necessary to secure payment.

DISCLAIMER: 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.

Insured’s Signature:

Date:

Request for Limitations and Restrictions of Protected Health Information

Please Note: The Practice is not required to agree to your request. Please see our notice of privacy practices for more information regarding such requests.

Patient Name:

D.O.B:

How would you like your Protected Health Information restricted?

DISCLAIMER: 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.

Signature of Parent/Guardian:

Today’s Date:

Patient Consent For Use And Disclosure Of Protected Health Information (PHI)

With my consent, A to Z Pediatrics may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to A to Z Pediatrics Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. A to Z Pediatrics reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to A to Z Pediatrics Privacy Officer at 4804 Rowan Rd, New Port Richey, FL 34653.

With my consent, A to Z Pediatrics may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance information and may call pertaining to my clinical care, including laboratory results among others.

With my consent, A to Z Pediatrics may mail to my home or other designation location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential. I have the right to request that A to Z Pediatrics restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my personal restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to A to Z Pediatrics use and discloser of my PHI to carry out TPO, and that I have received the notice of privacy practice form from A to Z Pediatrics. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do sign this consent, A to Z Pediatrics may decline to provide treatment to me.

DISCLAIMER: 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.

Signature or Parent/Legal Guardian:

Today’s Date:

Authorization For Treatment

Patient Name:

D.O.B:

SS#:

I hereby request and give permission for the physicians of A to Z Pediatrics to provide such medical examination and treatment as they deem best for the child’s physical or mental welfare.

The undersigned agrees to accept full responsibility for all charges due upon receipt of statement. I direct my insurer and third parties to pay directly to the physician office any insurance benefits due for services on behalf of the patient and I hereby assign to the physician’s office all my rights to receive payment from my insurer and third parties for services rendered by the physician’s office. I understand I am responsible for any costs incurred in the collection of the patient’s account in case of default, including reasonable attorney fees and/or court costs.

I agree that unless I give specific instructions otherwise, medical information regarding my child’s diagnosis and treatment may be released to the natural mother, natural father, stepmother/father, referring physician, other physician’s involved in the care of my child, and my insurance company(ies).

I, (parent or legal guardian) of the above patient gives permission to A to Z Pediatrics to seek medical treatment for my child.

Parent or Legal Guardian:

DISCLAIMER: 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.

Signature:

Today’s Date:

Physical Exam Disclaimer

Patient Last Name:

Patient First Name:

Patient Date of Birth:

Dear Parent/Guardian:
Pre-participation Physical Exams cannot guarantee or accurately predict that your child is risk free. It is well known and understood that certain sports produce injuries and that some cardiac anomalies may present even with “normal” results from a routine screening test. Therefore, normal results from routine screening tests should not be interpreted as indicating that he/she is free from risk or that all potential cardiac anomalies have been ruled out.

I have read and agree with the above statement.

DISCLAIMER: 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.

Signature:

Today’s Date:

Authorization to Release Patient Medical Information

Records to be released from:

Previous Doctor or Facility:

Phone#:

Fax#:

Records to be released for:

Child’s Name:

Date of Birth:

I hereby authorize and request you to release any and all medical records and other pertinent patient information, including the complete history, physical records, laboratory, x-rays, and/or any treatment or examination rendered to A to Z Pediatrics

For the purpose of diagnosis, care and treatment. You may refuse to sign this consent. This consent may be revoked at any time upon written notice, except to the extent that any person or organization has already taken action in release thereon. Information used or disclosed pursuant to this information may be subject to re-disclosure by the recipient and no longer protected.

Name (please print) of Parent/Guardian:

Phone Number:

DISCLAIMER: 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.

Signature of Parent/Guardian:

Relationship to Patient:

Date

Your information will be encrypted.