New Patient Registration Packet

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PATIENT INFORMATION FORM

Parent # 1 Information

Parent # 2 Information

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.

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.

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.

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.

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.

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.

PRIMARY INSURANCE INFORMATION

Please present a copy of your card to our receptionist.

Initial History Questionnaire

Household

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

Add new row for another household member

Birth History

During pregnancy, did mother

General

Development

If your child is in school:

Family History

Have any family members had the following:

Past History

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

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.

We are trying to obtain parents e-mail addresses.

There will not be any medical information emailed.

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

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.

(Name of Person/Agency)
(Name of Child)

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.

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.

(Mother, Father or Legal Guardian)

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