Patient Information Form

Please correct the errors described below.

INSURANCE INFORMATION

Add Additional Insurance

Parents, it is your responsibility to let the office know of any changes in address, insurance or phone numbers.

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.

hereby authorize my child's physician and whomever he/she may designate as his/her assistant or consultant to render medical treatment. I consent to any medical care which encompasses laboratory, diagnostic or medical treatment which my child's physician or his/her assistant or consultant may deem necessary during my child's treatment. I understand that my child's protected health information may be used and disclosed by PEDIATRIC KIDMED, L.L.C. for the purpose of treatment, payment, and health care operations. Please refer to the Notice of Privacy Practices* for further information on the use and disclosure of protected health information. You may review the notice before signing this consent.

I hereby authorize PEDIATRIC KIDMED, L.L.C. to provide medical records compiled during this visit for review and/or copying as requested by the insurance company, designated agent, or liable third parties whose benefits have been assigned for purposes of benefit payment for physician billing. I further authorize my child's treating physician to direct copies of his/her medical records to other physicians, hospitals, and other health care facilities, as they deem necessary.

The undersigned agrees, whether he signs as an agent or as a patient, that in consideration of the services to be rendered to the patient, the undersigned individually obligates himself to pay the account of the physician in accordance with the regular rates and terms of the physician. Furthermore, the undersigned is obligated to make weekly or monthly payments if requested. Should the account be turned over to a collection agency or an attorney for collection, the undersigned shall pay all collection fees. All delinquent accounts may bear interest at legal rates.

ACKNOWLEDGMENT FOR THE RECEIPT OF DOCUMENTS. I hereby acknowledge the receipt of the documents indicated, including the Notice of Privacy Practices.

I CERTIFY THAT I HAVE READ (OR HAVE HAD READ TO ME) AND FULLY UNDERSTAND THE ABOVE.

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.

The terms of the notice may be changed, a revised notice can be obtained at our office. Individuals have the right to request restrictions on use and disclosure of information for the purpose of treatment payment, or health care operations. We are not required to agree to such request, but if we do agree, such restrictions are binding. You may revoke this consent in writing, but the revocation does not affect any use or disclosure that has already occurred consistent with the consent.

(exclude vitamins & iron)

PAST MEDICAL HISTORY

Allergic reactions?

Hospitalizations

Serious injuries

FEEDING & NUTRITION

FAMILY PROFILE

FAMILY MEDICAL HISTORY

List all blood relatives of your child who have had the following problems - use abbrev. (F) Father, (M) Mother, (B) Brother, (S) Sister, (MM) Mother's Mother, (MF) Mother's Father, (FM) Father's Mother, (FF) Father's Father, (A) Aunt, (U) Uncle, (C) Cousin

DEVELOPMENT & BEHAVIOR

Age at which child

SYNOPSIS

ASSIGNMENT OF INSURANCE BENEFITS

I hereby authorize direct payment of surgical / medical benefits to Dr. for services rendered by him / her in person or under his / her supervision. I understand that I am financially responsible for any balance not covered by my insurance.

AUTHORIZATION TO RELEASE INFORMATION

to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit.

MEDICAID

I certify that the information given by me in applying for payment is correct. I authorize release of all records on request. I request that payment of authorized benefits be made on my behalf

A photocopy of these assignments shall be valid as the original

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.

Your information will be encrypted.

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