JUST FOR KIDS PEDIATRICS, PLLC

TODAY’S DATE:

PATIENT INFORMATION:

LAST NAME:

FIRST NAME:

MI:

DOB (month/day/year):

Sex:

Male Female

Preferred Name:

HOME PHONE:

MOBILE PHONE:

E-MAIL:

ADDRESS:

ZIP:

CITY:

STATE:

Do you want patient portal access?

Yes No

Consent to text?

Yes No

Consent to call?

Yes No

Enroll in Immtrac?

Yes No

GUARDIAN:

First Name:

Last Name:

Mother’s Name:

Phone:

Father’s Name:

Phone:

In Case of Emergency, contact:

Phone:

Relationship to patient:

GUARANTOR:

First Name:

Last Name:

DOB:

Patient’s relationship to guarantor:

Mailing address if different from patient:

How did you hear about us:

Previous patient

Referred by friend

Insurance

Mailer

Magazine

Google

Urgent care

Other

If you checked Referred by friend, please specify:

If you checked Magazine, please specify:

If you checked Other, please specify:

Acknowledgement of Office Policies

Patient’s name:

DOB:

For All Visits, please do the following:

Schedule an appointment; if a walk in appointment is scheduled, a $25.00 fee will incur.
Bring a current immunization record
Bring all relevant medical information (ex. discharge paperwork for newborns, ER & hospital visits discharge paperwork, relevant lab results and imaging results)
Submit current insurance information prior to appointment
Be on time and come early.
Bring any forms requiring physician signature (e.g daycare forms, physicals, medication administration at school, etc) with you to your scheduled appointment; otherwise there will be a 48-72 hour turn around time.

At Just For Kids Pediatrics, we believe that all children should be fully immunized unless there are medical contraindications, and this policy advocates for all children and their best interest. We feel vaccines are significantly safer than the disease states. We request that patients are up to date on well exams and establish a medical home to continue to be seen in our office.

INITIAL VISITS: For your initial visit to Just for Kids Pediatrics there are forms you must fill out prior to being seen. Registration forms are available on our website under patient forms. Once you are accepted and registered with our practice, we will contact you to confirm. Once registered, we strongly encourage you to use the patient portal service to better communicate with our office, and have access to your child’s medical records. Please come 15 minutes prior to your appointment so that you will have enough time to complete the forms if not completed prior to your visit.

NO SHOWS. It is very important to respect everyone’s time and it is unfair to others if you do not show on time for your scheduled appointment. If you have an appointment and cannot make it, please contact us as soon as possible to either cancel or re-schedule your appointment. There will be a $25.00 charge if you do not notify us 1 business day prior to your appointment (e.g notify the office on Friday if unable to make it your Monday appointment).

AFTER HOURS.

In the event of an emergency, first dial 911 and then contact us at our office.
If you suspect your child has swallowed medicine or poison, dial Poison Control at 1-800-222-1222.
Do not call for maintenance prescription refills after hours. This will be handled during regular business hours.
Antibiotics, eye drops, steroids, other prescriptions will not be called in without an evaluation. If you feel any of these are necessary treatments, seek medical care.
If your child needs to be evaluated after hours we recommend Night Light Pediatrics at www.nightlightpediatrics.com or Texas Children’s Urgent Care at www.texaschildrens.org

I have read and understand the above office policies; and am willing to comply with the office policies set forth by Just for Kids Pediatrics.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Parent/Legal Guardian:

Date:

Printed Name of Parent/Legal Guardian:

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY (SEE PRIVACY NOTICE)

By signing below, you acknowledge that you have read, and been given the opportunity to receive a copy of the Notice of Privacy prior to any service being provided to you by Just for Kids Pediatrics, and you consent to the use and disclosure of your medical information as set forth except as expressly stated below.

I hereby request the following restrictions on the use and/or disclosure (specify as applicable) of my information.

Patient Name:

Patient DOB:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient/Legal Representative:

Date:

Relationship to Patient:

Witness: (optional)

Date:

ACKNOWLEDGEMENT OF FINANCIAL POLICY AND ASSIGNMENT OF BENEFITS

Our office provides insurance claim processing as a courtesy. The ultimate responsibility of payment and authorization of benefits belongs to the patient. Accepted methods of payment include VISA, Mastercard, Discover, checks, and FSA cards.

Patient responsibilities:

Bring in current insurance card and valid ID at every visit.
Proof of insurance is not a guarantee of coverage or payment.
Pay fully all your co-payments, outstanding balances, deductibles, recommended services not covered by your insurance carrier, and charges incurred during your child’s care and treatment.
If your child has an insurance plan that Just for Kids Pediatrics does not contract with, then you will be responsible for payment in full at time of service. We do offer prompt payment discount for self-pay patients.
If your insurance plan requires you to choose a primary care physician, it is your responsibility to select a physician within the practice, otherwise you will be a self pay patient until you have chosen one of our physicians as your PCP.
In situations involving divorce or separation, the legal guardian or the person authorized to bring the child in for care will be financially responsible for that visit
No show policy. A no show is considered when cancellation in less than 1 business day. Missed appointments or appointments not cancelled within 1 business day will be considered as no show and will incur a charge of $25.00. Also, if an appointment is rescheduled more than 3 times, it will incur a charge of $25.00.

I authorize payment of medical benefits to Just for Kids Pediatrics, PLLC for any services provided to my child by the practice. I authorize you to release my child’s insurance company or their agent, information concerning healthcare, advice, treatment, or supplies provided to my child. This information will be used for claims of benefits. This assignment of benefits shall remain valid until written notice is provided by me.
I have read and understand the stated financial policy and assignment of benefits.

Child’s name:

DOB:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Parent/Legal Guardian:

Date:

Printed name of Parent/Legal Guardian:

Relationship to patient:

Your information will be encrypted.