Patient Registration Form

Pediagroup Associates

Please correct the errors described below.

Patient Information

Child's Full Name

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Emergency Contacts

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Guarantor Information (Person Financially Responsible)

Insurance Information

Allergies

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HISTORY

Birth History:

Surgical History

Family History:(Check all boxes that apply)

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  • M = Maternal – Patient’s mothers side of family
  • P = Paternal – Patient’s mothers side of family

Home Environment

Parent’s Status

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

With my consent, PEDIAGROUP ASSOCAITES may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to PEDIAGROUP ASSOCIATES’s Notice of Policy 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. PEDIAGROUP ASSOCIATES 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 Privacy Officer at PEDIAGROUP ASSOCIATES. With my consent, PEDIAGROUP ASSOCIATES may call my home or other designated location and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others. With my consent, PEDIAGROUP ASSOCIATES may mail to my home or other designated 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. With my consent, PEDIAGROUP ASSOCAITES may email to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that PEDIAGROUP ASSOCIATES restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to PEDIAGROUP ASSOCIATES’s use and disclosure of my PHI to carry out TPO. 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 not sign this consent, PEDIAGROUP ASSOCIATES may decline to provide treatment to me.

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.

PediaGroup Financial Polices

We at PediaGroup are committed to providing you with the quality care, and we are pleased to discuss out professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. Parent/Guardians are responsible for all services provided at the time of the visit. This includes co-pays, deductibles, co-insurance and non-covered services. For your convenience, we accept credit cards, check or cash. We will file a claim to your primary insurance as a courtesy. However, you are responsible for any remaining balances. Any outstanding account over 60 days must be settled prior to any future appointments. It is the parents/ guardians responsibility to contact the insurance carrier to determine which changes may or may not be covered. An outstanding balance of more than 90 days will be deemed delinquent and referred for collection. Uninsured or non-contracted patients are responsible for payment-in-full at the time of service. Returned checks for non-sufficient funds (NSF) will be billed an additional fee of $25.00. Please be aware that if a significant health issue is addressed during a routine check-up or physical, this is a modified well visit and may result in a co-payment. PediaGroup does not get involved in disputes between divorced parents regards financial responsibility for their child’s medical expenses. By signing you agree to be financially responsible for the care we provide to your child, regardless of whether a divorce or other arrangement places that obligation on former spouse. Appointment cancellations are expected at least 24 hours prior to the appointment. We reserve the right to charge for medical record copying services.

Authorization of treatment, Release of Information and assignment of Benefits:

I authorize the providers a PediaGroup Associates to treat my child. I further authorize the release of any medical information necessary to process a related claim and request payment of benefits to the party who accepts assignment. I understand that I am financially responsible for any balance not covered by my insurance. I hereby authorize PediaGroup Associates, to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit. 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.

This Policy may be subject to change.

Authorization – Non- Parent/ Guardian to Accompany Patient

Periodically there may be times when you are unable to bring your child to the office for an appointment and need to rely on a family member or friend. We understand these circumstances; however, we must have a written authorization letter allowing this person to accompany your child (ren). The person bringing her your child will need to present photo identification at time of service. This authorization five the person permission to bring your child(ren), speak to the doctor, give authorization for treatment, vaccinations, medication, certain procedures and make general health decisions.

I also give them authority to make serious or urgent health care decisions in the event I cannot be reached or where it is of an emergency nature where there is not sufficient time to seek out my specific consent.

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(IF ONLY PARENTS ARE ALLOWED TO BRING CHILD IN, PLEASE INDICATE “NONE”)

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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.

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