New Patient Registration Packet

PATIENT INFORMATION FORM

Patient Name - Last Name:

First Name:

Middle Initial:

Date of Birth:

Birth Hospital:

Sex:

Address:

Apt #:

City:

State:

Zip:

Home Phone:

Mobile:

Emergency Contact:

Telephone #:

Relationship to Child:

Parent # 1 Information

Parent Name - Last Name:

First Name:

Date of Birth:

Sex:

Social Security #:

Maiden Name:

Address: (If different from Child)

City:

State:

Zip:

Email:

Employer:

Work #:

Mobile #:

Parent # 2 Information

Parent Name - Last Name:

First Name:

Middle Initial:

Date of Birth:

Sex:

Social Security #:

Maiden Name:

Address: (If different from Child)

City:

State:

Zip:

Email:

Employer:

Work #:

Mobile #:

IMPORTANT OFFICE POLICIES

ASSIGNMENT OF MEDICAL BENEFITS

I authorize my insurance carrier to assign all medical benefits to Children's Healthcare Associates, P.C. I also authorize the release of medical information necessary to process all medical insurance claims. Please note we DO NOT accept assignment on secondary insurances under any circumstance. This includes and is not limited to private insurance or any state provided health plan such as ALL KIDS, MEDICAID or KIDCARE. Therefore, all copays/deductibles and coinsurance amounts are your responsibility.

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PAYMENT POLICY

Co-payments are due at the time services are rendered. We accept cash, checks and all major credit cards. Children's Healthcare Associates is contracted with many different insurance plans.
It is the Parents responsibility to check with their insurance plan for policy provisions and to check if their doctor is contracted with their specific plan. Our physicians provide care according to the American Academy of Pediatrics and not based on what is covered by an Insurance plan. You will be responsible for any balance deemed patient responsibility/non-payable/non-covered by your insurance and billed accordingly. Payment is expected in full upon receipt of statement or payment arrangements must be made with our billing office. In the result your account is referred to an outside collection agency, our office will add an additional 33% to your account total for the service fees associated.

Please be advised that under state laws, both father and mother are responsible for the medical necessities of their dependent children, regardless of any separation or divorce agreements. Therefore, Children's Healthcare Associates observes the following guidelines.

• Statements will be directed to the home where the child resides. It is that parent's responsibility to forward bills for payment.
• We will assist you in filing insurance claims and providing duplicate copies of invoices as needed.
• Children's Healthcare Associates will not act as an arbitrator for a separation or divorce settlement with respect to determining responsibility for payment of bills.

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INSURANCE CARDS

It is mandatory that you inform the office when a change of insurance occurs. Due to timely filing limits if insurance is not updated in a timely fashion, the entire claim will become your responsibility.

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CANCELLATION POLICY

Our office requests if an appointment needs to be cancelled, we receive notice no later than 24-hours prior to the appointment. We reserve the right to charge $30.00 for no show appointments or cancellations with less than 24-hour notification. This is to be collected on or before your next appointment.

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AFTER HOUR CALLS

ALL after hour calls will be assessed a $25 fee. This is not covered by Insurance and you will be billed directly. You are utilizing the physician's expertise outside of regular business hours and there are additional costs associated for handling patient calls when the office is closed.

REFERRAL POLICY

If your Insurance company requires a referral it is your responsibility to contact our Care Coordinator to obtain the proper documentation. We require 72-hour notice for referrals.

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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.

Signature:

PRIMARY INSURANCE INFORMATION

Name of Insurance Company:

Type of Plan:

Group #:

ID #:

Insurance Company Phone #:

Effective Date:

Name of Insured:

Please present a copy of your card to our receptionist.

Initial History Questionnaire

Form Completed By:

Date Completed:

Name:

ID Number:

Birth Date:

Age:

Household

Please list all those living in the child's home.

Name:

Relationship to child:

Birth date:

Health problems:

Add new row for another household member

Are there siblings not listed? If so, please list their names and ages and where they live.

If mother and father are not living together or if child does not live with parents, what is the child's custody status?

If one or both parents are not living in the home, how often does he/she see the parent/parents not in the home?

Birth History

Birth weight:

Was the baby born at term?

Early?

Late?

If early, how many weeks' gestation?

Did mother have any illness or problem with her pregnancy?

Yes No

Explain:

During pregnancy, did mother

Smoke:

Yes No

Drink alcohol:

Yes No

Use drugs or medications:

Yes No

What:

When:

Was the delivery:

Vaginal Cesarean

If cesarean, why?

Did your baby have any problems right after birth?

Yes No

Explain:

Was initial feeding:

Breast Bottle

Did your baby go home with mother from the hospital?

Yes No

Explain:

General

Do you consider your child to be in good health?

Yes No

Explain:

Does your child have any serious illness or medical condition?

Yes No

Explain:

Has your child had serious injuries or accidents?

Yes No

Explain:

Has your child had any surgery?

Yes No

Explain:

Has your child ever been hospitalized?

Yes No

Explain:

Is your child allergic to any medicines or drugs?

Yes No

Explain:

Development

Are you concerned about your child's physical development?

Yes No

Explain:

Are you concerned about your child's mental or emotional development?

Yes No

Explain:

Are you concerned about your child's attention span?

Yes No

Explain:

If your child is in school:

How is his/her behavior in school?

Has he/she failed or repeated a grade in school?

How is he/she doing in academic subjects?

Is he/she in special or resource classes?

Family History

Have any family members had the following:

Deafness:

Yes No

Who:

Comments:

Nasal allergies:

Yes No

Who:

Comments:

Asthma:

Yes No

Who:

Comments:

Tuberculosis:

Yes No

Who:

Comments:

Heart disease (before 50 years old):

Yes No

Who:

Comments:

High blood pressure (before 50 years old):

Yes No

Who:

Comments:

High cholesterol:

Yes No

Who:

Comments:

Anemia:

Yes No

Who:

Comments:

Bleeding disorder:

Yes No

Who:

Comments:

Liver disease:

Yes No

Who:

Comments:

Kidney disease:

Yes No

Who:

Comments:

Diabetes (before 50 years old):

Yes No

Who:

Comments:

Bed-wetting (after 10 years old):

Yes No

Who:

Comments:

Epilepsy or convulsions:

Yes No

Who:

Comments:

Alcohol abuse:

Yes No

Who:

Comments:

Drug abuse:

Yes No

Who:

Comments:

Mental illness:

Yes No

Who:

Comments:

Developmental Delay:

Yes No

Who:

Comments:

Immune problems, HIV, or AIDS:

Yes No

Who:

Comments:

Additional family history:

Past History

Does your child have, or has he/she ever had:

Chickenpox:

Yes No

When:

Frequent ear infections:

Yes No

Explain:

Problems with ears or hearing:

Yes No

Explain:

Nasal allergies:

Yes No

Explain:

Problems with eyes or vision:

Yes No

Explain:

Asthma, bronchitis, bronchiolitis, or pneumonia:

Yes No

Explain:

Any heart problem or heart murmur:

Yes No

Explain:

Anemia or bleeding problem:

Yes No

Explain:

Blood transfusion:

Yes No

Explain:

Frequent abdominal pain:

Yes No

Explain:

Constipation requiring doctor visits:

Yes No

Explain:

Bladder or kidney infection:

Yes No

Explain:

Bed-wetting (after 5 years old):

Yes No

Explain:

(For girls) Has she started her menstrual periods:

Yes No

When:

(For girls) Are there problems with her periods:

Yes No

Explain:

Any chronic or recurrent skin problem (acne, eczema, etc):

Yes No

Explain:

Frequent headaches:

Yes No

Explain:

Convulsions or other neurologic problem:

Yes No

Explain:

Diabetes:

Yes No

Explain:

Thyroid or other endocrine problem:

Yes No

Explain:

Any other significant problem:

Yes No

Explain:

Use of alcohol or drugs:

Yes No

Explain:

SICK Visits vs Well visits or Both?

Sick Visit -- This is an office visit for an acute problem or flare-up of a chronic problem. This could also be an office visit to follow up on chronic problems (ADHD, nutritional, counseling, asthma, ear infections, new or refill prescriptions, review and discussion of ongoing treatments or concerns)

Well Visit -- This is an office visit for a routine physical exam or yearly health maintenance exam.

Sick/Well Visit -- This is a combination visit of a routine physical exam where an acute or chronic issue is addressed as well. For example, if you presented today for a well visit and you have an acute or chronic issue you would like addressed, it is considered a combination visit and must be billed differently than just a well visit or just a sick visit.

Why it is billed differently -- It is billed differently to account for the additional work, expertise and time required for a combination visit (additional lab work, x-ray, referrals and; /or prescription medications). It involves additional documentation as well. Our insurance contracts require we bill for ALL services rendered.

How this affects me -- Although many insurance companies acknowledge the sick/well visit combination, some of them still require the patient to pay co-pays or have additional costs applied to the annual deductible.

ANNUAL PHYSICAL EXAMS

Annual physical exams target preventative care and are billed as such. Medication refills and/or other ailments injuries, or illnesses addressed during an annual physical exam are billed IN ADDITION to the annual physical. These charges may be passed on to the patient. Please check with your insurance company to confirm your coverage for all types of doctor visits.

We realize this can be confusing, and if you have any questions or concerns after reviewing this material, please ask.

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.

Child's Name:

Parent's Signature:

Child's Date of Birth:

Today's Date:

We are trying to obtain parents e-mail addresses.

Child's Name:

Child's DOB:

Parent Name:

Email address:

There will not be any medical information emailed.

OK to email: (Select all that apply.)

Appointment information

Forms

Billing inquiries

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.

Parent Signature:

Date:

Consent for Medical/Surgical Care/Emergency Treatment and Child's Medical Information

Name:

Child's Name:

Relation to child:

Mother

Father

Legal Guardian

Child:

Son

Daughter

Child's age:

In presenting my son/daughter for diagnosis and treatment, I hereby voluntarily consent to the rendering of such care, including diagnostic procedures, surgical and medical treatment and blood transfusions, by authorized members of the hospital staff or their designees, as may in their professional judgment be necessary.

I hereby acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on my child's condition.

I have read this form and certify that I understand its contents.

We/l hereby give our (my) consent to

(Name of Person/Agency)

who will be caring for our (my) child

(Name of Child)

for the period:

to:

to arrange for routine or emergency medical/dental care and treatment necessary to preserve the health of our (my) child.

We/l acknowledge that we are (I am) responsible for all reasonable charges in connection with care and treatment rendered during this period.

Name:

Family physician:

Address:

Pediatrician:

Telephone no.:

Surgeon:

Name of health insurance carrier:

Orthopedist:

Group no.:

Child's allergies, if any:

Date of last tetanus booster:

Agreement no.:

Medicines child is taking:

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.

Signature:

(Mother, Father or Legal Guardian)

Date:

Witness:

Date:

In case of emergency I can be reached at:

PATIENT DEMOGRAPHIC INFORMATION

PLEASE CHOOSE AN ANSWER FOR EACH OF THE 3 SECTIONS BELOW:

ETHNICITY:

Hispanic/Latino Non-Hispanic/Latino Decline to Specify

RACE:

White Black American Indian/Alaska Native Asian Native Hawaiian and Other Pacific Islander Other race Decline to Specify

Other race, (Specify)

PREFERRED LANGUAGE

English Spanish Arabic Chinese Polish Other: Decline to Specify

If other, Specify:

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