Parent/Legal Guardian Information (for example mother)
Parent/Legal Guardian Information (for example father)
Sibling Information (other children) who received care from our office)
Primary Insurance - A copy of your card is required and it is your responsibility to keep us updated of any change.
Emergency Contact Information (other than parents)
In the absence of the parent/legal guardian, I give the following person(s) permission to seek treatment (including Immunizations) for my child/children. I also realize that the person with my child may have access to pertinent protected health information if medically necessary.
Pharmacy
Release of Protected Health Information
I give permission to release protected health information to: My daycare/school upon request. Other healthcare providers for purposes related to your care and treatment, or we may use and disclose your health information in order to bill and collect payment for services and items you receive.
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.
It is our intention to provide your child (ren) the best care possible at all times and to accommodate as many requests as is realistic and feasible. It is within this context that we ask you take a few moments to review policies that affect the way services are provided.
In the Office
After –hours Call Service
We are here to provide the best care we can to your child (ren) should the need arise. As always, we welcome the opportunity to care for your child (ren) and appreciate your trust in the services we provide.
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.
PLEASE LIST EACH CHILD THAT IS A PATIENT IN OUR OFFICE
PLEASE FILL OUT THE FOLLOWING INFORMATION
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.
As a courtesy, Prestige Pediatrics, verifies your benefits with your insurance company. A quote of benefits is not a guarantee of benefits or payment. Your claim will process according to your plan, if your claim processes differently from the benefits we were quoted, the insurance company will side with the plan and will not honor the benefit quote we received.
It is the policy of Prestige Pediatrics that payment is due at the time of service unless other financial arrangements are made in advance. We require that all patients pay their deductible, copay and/or coinsurance payment at the beginning of each visit. The Office Coordinator will explain this information to you prior to your first visit. At the conclusion of your visits with us, you may be billed for any outstanding balances. If there is a credit, you will be provided a refund promptly.
If you are covered by health insurance with pediatric benefits, we will be happy to bill your insurance. Please provide your insurance information to the front office staff and we will verify your coverage as a courtesy. Accepting your insurance does not place all financial responsibilities onto this practice, and you will be held accountable for any unpaid balances by your plan.
Although we are contracted with most insurance carriers, our services may not be covered by your particular insurance plan. Being referred to our clinic by another physician does not necessarily guarantee that your insurance will cover our services. Please remember that you are 100 percent responsible for all charges incurred: your physician's referral and our verification of your insurance benefits are not a guarantee of payment.
We highly recommend you also contact your insurance carrier to make sure our office is in network and check into your coverage for pediatric benefits. Do not assume that you will not owe anything if you have more than one insurance policy.
Policy on Co-Pay Requirements When a Sick Visit Is Added To a Well Child Visit
Prestige Pediatrics is required under contract with your insurance carrier to collect co-pays at the time of medical service, most commonly sick visits. You will be charged a co-pay if you either request, or approve, treatment for an acute or chronic illness during a Well Child Visit. Such a request constitutes a Sick Visit, in addition to the Well Child Visit.
By signing below, you agree to the above financial policy. You also agree that you have provided Prestige Pediatrics ALL insurance plans in which your child is covered.
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.
I understand that prescription history from multiple unaffiliated medical providers, insurance companies, and pharmacy benefit managers may be viewable by my providers and authorized staff here and may include prescriptions from several years ago.
My signature certifies that I read and understood the scope of my consent and that I authorize access.
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.
Please list commonly used Pharmacy Information:
Your information will be encrypted.