18 Year and Up Patient Demographics

Please correct the errors described below.

Primary Insurance information:

  • Insurance coverage is a contract between you and your insurance company. It is your responsibility to know what your plan does and does not cover.
  • We will file insurance claims for you , but you are responsible for amounts not paid by insurance. I also understand that all co-payments, deductibles, and co-insurance are due at the time of service.
  • I authorize payment of medical benefits to be made directly to Poole & Thomas Pediatrics for services performed. I further agree to be fully responsible for all lawful debts incurred for services provided.
  • I consent to be contacted by regular mail, email or by telephone (including a cell phone number) regarding any matter related to my account with Poole & Thomas Pediatrics.

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

Consent to Treat/ Medical Records/ Privacy 18 years & Older

hereby authorize and consent to the examination and/or treatment during office and facility visits by the physicians and clinical staff of Poole & Thomas Pediatrics.

By signing below, I authorize Poole & Thomas Pediatrics to release my medical and billing information to:



If there is ever a change in this request, please notify the staff of Poole and Thomas Pediatrics.

Acknowledge of Receipt of Consent to Use and Disclose Health Information

This office is required by Federal Regulations to inform our patients to the use of your health information accordance to Health Information Portability and Accountability Act or HIPAA.

I understand that as a part of my health care, Poole and Thomas Pediatrics originates and maintains paper records describing my health history, symptoms, examinations, test results, diagnosis, treatments, and any plans for future care or treatment. I understand that this information serves as:

  • A basis for planning my care and treatment.
  • A means of communication among health professionals who contribute to my care.
  • A source of information for applying my diagnosis and treatment information to my bill.
  • A means by which a third-party can verify the services billed to me actually took place.

I understand and have been provided access to a Notice of Privacy Practices that provide a more complete description of information uses and disclosures. This notice is located on our website ptpediatrics.com and is located in paper form at the check-in window of our office. I understand that I have the following rights and privileges:

  • The right to review the Notice of Privacy Practices prior to signing this consent, allowing treatment, or making payment for services rendered and the right to a paper copy of the Notice of Privacy Practices.
  • The right to object to the use of my health information for directory purposes.
  • The right to request confidential communications.

I acknowledge that I have received the Consent to Use & Disclose Health Information, which explains how my health information will be handled in various situations


At Poole and Thomas Pediatrics, we are committed to protecting the security and privacy of your child’s personal information. Medical records are the property of Poole and Thomas Pediatrics. These records are kept in a secure location, and are accessed only for the purposes outlined by the Notice of Privacy Practices (Revised 9/23/13). Our revised Privacy Notice is available at www.ptpediatrics.com , or you may request a copy from our office. Records may be released or shared with other healthcare professionals for the treatment of your child. Patients are entitled to one free copy of their medical records only after an authorization for release is signed. Additional copies may be made for a fee of $1.00 per page, per KY House Bill 250.

  • By signing below, I acknowledge that I have received Poole and Thomas Pediatrics Notice of Privacy Practices and consent to treat information. I understand that I can edit any of the terms below. I understand that PTP may call my home and place of employment for healthcare reasons, appointment reminders, to resolve billing issues, and may mail me information postcards to my home address. PTP may also mail bills to my mailing address.
  • I understand that PTP may leave messages on my answering machine regarding appointments and limited lab information.
  • I understand that PTP may use an email address, text messaging or fax, provided by me to communicate appointment information, billing issues, immunization certificates, lab and test results, and other forms requested by the parent.
  • I authorize PTP to email or fax immunization certificates and/or school forms, or to mail to my home address provided.
  • I authorize PTP to discuss patient information with adults or other minors present during the visit regardless whether I am present.
  • I understand that if I send a picture of myself or child(ren) PTP may display it within the office.

My signature below indicates I am the patient listed above, that I have provided accurate information to the best of my knowledge and I understand and agree to the provision above.

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