New Patient Packet

Please correct the errors described below.

Parent/Legal Guardian Information (for example mother)

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Parent/Legal Guardian Information (for example father)

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Sibling Information (other children) who received care from our office)

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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.

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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.

POLICY

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

  • Arrive early. Please remember that all insurance plans require that your insurance data be updated prior to each visit. This usually takes a few minutes and we ask for your patience. If this is not done, your insurance company may deny your claim. We do not want time spent on administrative requirements to limit your time with the doctor.
  • Schedule an appointment by calling (229) 903-4044. Walk-in patients are strongly discouraged. If you have a sick child, we ask that you call the office and allow the office staff to triage your child to see if an urgent visit is needed or if the child can be treated with a prescription. Urgent visits are based on the nature of the illness and on a first available appointment basis. Please be mindful that some urgent visits require the patient to be seen before scheduled appointments and our staff will do their best to keep on schedule. We thank you for your understanding.
  • Siblings. We will do our best to schedule siblings on the same day however that is not always possible for various reasons. If you are bringing a child to a scheduled appointment and one of the siblings needs to be seen as an urgent visit, we ask that you call in advance and schedule an appointment.
  • Appointment times. It is important that you bring your child (ren) to their appointment at the time we have allotted for your child (ren). Patients who have arrived on time will be seen ahead of those who arrive late. If you arrive late, we will work you in between the scheduled patients or reschedule your child (ren’s) visit.
  • Late arrivals. In the case that you will not be able to make your appointment we ask that you call the office and make us aware of your situation. The office allows a 15 minute grace period and after that time the appointment will need to be rescheduled to the next available appointment.
  • Missed appointments. If you are not able to make an appointment it is critical that you call the office at least two (2) hours in advance. If it is after hours, call the office number and leave a message on the voicemail. Our staff will get the message and cancel the appointment. We ask that you call back during office hours to reschedule the missed appointment. Please note: Appointments that are missed without a phone call will be considered as a No Show appointment. If you have two (2) or more No Show appointments within 6 months you will receive a letter from our office. At the third (3rd) No Show appointment, you will receive a non-compliance/dismissal letter from our office for the patient and all siblings.
  • New patient appointments. If you schedule an appointment for your child and it is their first visit, it is imperative that you call to cancel/reschedule that appointment if you are not able to make that visit. If this is not done we will not be able to reschedule you another appointment.
  • No show appointments deny other patients the opportunity to receive medical care when needed.
  • Forms. Please allow us 24 – 48 business hours to fill out any forms that are dropped off to be completed.
  • Turn off cell phones in the office and examination rooms.

After –hours Call Service

  • Please limit after- hour calls to URGENT issues and EMERGENCIES.
    • For refills, appointments, and non urgent matters, call the office during normal business hours.
  • When leaving a message
    • Please listen to the prompt, speak clearly and slowly.
    • State the child’s name and date of birth.
    • State the parent/guardian’s name
    • Enter correct call back number as prompted by the system.
    • Disable your call block feature.
    • Follow the doctor’s instructions.
    • If call has not been returned within twenty (20) minutes, please call again.

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

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DEMOGRAPHICS

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.

FINANCIAL POLICY

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.

CONSENT TO OBTAIN EXTERNAL PRESCRIPTION HISTORY

whose signature appears below, authorize Prestige Pediatrics, P.C. to view my child(ren) external prescription history via our electronic health record system, eClinicalWorks.

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:

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