PATIENT INFORMATION **PLEASE LIST EVERYONE THAT IS CURRENTLY A PATIENT HERE AT OUR PRACTICE**
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RESPONSIBLE PARTY'S INFORMATION *PLEASE LIST GUARDIAN THAT IS FINANCIALLY RESPONSIBLE HERE*
ADDITIONAL PARENT / LEGAL GUARDIAN'S INFORMATION
EMERGENCY CONTACT INFORMATION: ******OTHER THAN THE PARENT/GUARDIANS LISTED ABOVE******
ADDITIONAL PERSONS AUTHORIZED TO BRING PATIENTS / CONSENT FOR TREATMENT ON YOUR BEHALF: (OVER 19)
INSURANCE INFORMATION
CONSENT FOR TREATMENT: I CONSENT TO THE NECESSARY TREATMENT INCLUDING: DRUGS, MEDICINES, IMMUNIZATIONS PERFORMED PROCEDURES, OR OTHER STUDIES THAT MAY BE USED BY THE ATTENDING PHYSICIAN, NURSE, OR STAFF. I CONSENT TO THE USE OF THE ABOVE CONTACT INFORMATION TO COMMUNICATE PERSONAL HEALTH INFORMATION TO THE PARENTS/GUARDIANS LISTED ABOVE.
AUTHORIZATION FOR RELEASE OF INFORMATION: I AUTHORIZE ALABASTER PEDIATRICS TO FURNISH ANY MEDICAL INFORMATION REQUESTED BY INSURANCE COMPANIES WITH WHOM I HAVE COVERAGE OR PUBLIC AGENCY WHICH MAY BE ASSISTING IN PAYMENT OF PATIENT'S CARE AND/OR ANY DOCTOR REFERRING PT. FOR TREATMENT
ASSIGNMENT OF BENEFITS: I HEREBY AUTHORIZE PAYMENT DIRECTLY TO ALABASTER PEDIATRICS OF BENEFITS OTHERWISE PAYABLE TO ME INCLUDING MAJOR MEDICAL INSURANCE AND PAYMENTS OF SURGICAL OR MEDICAL BENEFITS, BUT NOT TO EXCEED THE ALABASTER CHARGES FOR THESE SERVICES. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE TO ALABASTER PEDIATRICS FOR CHARGES NOT COVERED BY THIS ASSIGNMENT. I AUTHORIZE THE REFUND OF OVERPAID CLAIMS WHERE MY COVERAGES ARE SUBJECT TO A COORDINATION OF BENEFITS.
GUARANTEE OF ACCOUNT: FOR SERVICES FURNISHED BY ALABASTER PEDIATRICS, I HEREBY GUARANTEE THE PAYMENT OF ALL ACCOUNTS FOR SERVICES RENDERED FOR PAYMENT OF THE SAID ACCOUNTS FOR SERVICES, I HEREBY WAIVE ALL CLAIMS OF EXEMPTION UNDER THE STATE OF ALABAMA AND AGREE TO PAY ALL FEE COSTS.
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.
NON-COVERED SERVICES STATEMENT: If you have any questions about whether or not a particular service is covered by your health benefits contract or the amount of the services being rendered please contact your insurance company. Depending on your health benefits contract you may have some services which may not be covered by your insurance contract. You will be expected to pay for these services, in full following notification from your insurance carrier of coverage. As your child’s provider, we will order only the test and treatments that we feel are necessary for your child’s treatment and care. Thank you for understanding.
MEDICAID: I understand that if I do not have a Medicaid referral from my assigned PMP on the date of service, I will be responsible for any charges incurred.
EXAMPLES OF POSSIBLE NON–COVERED SERVICES FOR PREVENTIVE (ROUTINE) CARE WHICH MAY BE PROVIDED TODAY BY YOUR PHYSICIAN AND/OR STAFF ARE LISTED BELOW:
PHYSICIAN SERVICE: Preventive Care Physician Fee (Well Child Visit), Hearing and Vision Screenings.ADDITIONAL TREATMENTS: Issues addressed during WCC that would constitute an additional office visit charge.LABS: CBC/Hematocrit/Blood Draw fee, Urinalysis and CholesterolVACCINES: Vaccines/Antibiotic Injections/ Vaccine AdministrationOTHER: Allergy Testing including lab charges, Developmental Testing and any other possible non-covered service.
I have read your policy and agree to pay for the services outlined in the policy that are not covered by my insurance contract as indicated by my signature for each visit my child incurs in this current calendar year.
ALABASTER PEDIATRICS IS AUTHORIZED TO RELEASE PROTECTED HEALTH INFORMATION TO IDENTIFIED PERSONS BELOW ABOUT THE ABOVE NAMED PATIENTS IN THE FOLLOWING MANNER:
CHECK EACH ENTITY YOU APPROVE TO RECEIVE INFORMATION
CHECK EACH ENTITY THAT YOU APPROVE TO BE RELEASED
***DISCLOSURE*** FOR TEXT/EMAIL COMMUNICATIONS, I UNDERSTAND THAT THE INFORMATION IS NOT SENT IN AN ENCRYPTED MANNER, THEREFORE IT COULD BE ACCESSED IN AN INAPPROPRIATE WAY, I STILL ELECTED TO RECEIVE.
PATIENT RIGHTS
I HAVE THE RIGHT TO REVOKE THIS AUTHORIZATION AT ANY TIME.
I MAY INSPECT/COPY THE PROTECTED HEALTH INFORMATION TO BE DISCLOSED AS DESCRIBED IN THIS DOCUMENT REVOCATION IS NOT EFFECTIVE IN CASES WHERE THE INFORMATION HAS ALREADY BEEN DISCLOSED, BUT WILL BE EFFECTIVE GOING FORWARD.
INFORMATION USED OR DISCLOSED AS A RESULT OF THIS AUTHORIZATION MAY BE SUBJECT TO REDISCLOSURE BY THE RECIPIENT AND MAY NO LONGER BE PROTECTED BY FEDERAL OR STATE LAWS.
I HAVE THE RIGHT TO REFUSE TO SIGN THIS AUTHORIZATION AND MY TREATMENT WILL NOT BE CONDITIONED ON THIS.
THIS AUTHORIZATION WILL REMAIN IN EFFECT UNTIL REVOKED BY THE PATIENT.
Good health care for newborns, infants, children, and adolescents begins with the well-child visit (checkup) and other services that help keep children healthy. These are preventive services. Our doctors and staff provide these services based on a plan called Bright Futures. The American Academy of Pediatrics (AAP) made this plan to help doctors and families know what preventive services children should receive from birth to 21 years of age, such as screening tests, and advice about staying healthy and safe. This plan can be altered to suit each child as needed. We also follow the AAP vaccine schedule for newborns, infants, children’s and adolescents.
Because preventive services are important to keeping children healthy, the Patient Protection and Affordable Care Act (health care reform law) includes a rule that all preventive care screenings and services included in the Bright Futures plan and vaccines schedule must be covered by most health plans. This is not always true, though, as some older plans, called grandfathered plans, do not have to pay in full for preventive services. There may also be times when a child needs a service that is not considered preventive on the same day as a well-child visit. If a child is not well or a problem is found or needs to be addressed during the check-up, the physician may need to provide an additional office visit service (called a sick visit) to care for the child. This is a different service and is billed to your health plan in addition to the preventive services provided on that day. If you have a copayment for office visits or coinsurance or deductible amounts that you must pay before your health plan pays for these services, our office will charge you these amounts.
We value your time and want to make the most of each appointment for the child. This is why we will address any problem that needs a doctor's care during well-child visits so that only one trip is needed. Some services that may be provided and billed in addition to preventive services include:
Our office does not want you to be surprised by a charge, but our contract with your insurance company requires we always bill your health plan based on the actual services provided. Please feel free to ask our billing staff about services that may not be paid in full by your health plan. As always it is our pleasure to help.
HOUSEHOLD (please list all those living in the child's home)
Pregnancy
Delivery
Newborn
Do you have any concerns about your child's:
Does your child have, or has he/she ever had:
If a family member has or has had any of the following problems, please check the box and note the family member M = mother F= father S= sibling GM= grandmother GF = grandfather A = Aunt U = Uncle
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