Patient Demographics

Patient's Name (First Name)

Last Name

Middle

Home Address

City

State

Zip

Date of Birth

Ethnicity

Preferred Language

IF YOU ARE NOT THE PARENT OF THIS CHILD AND / OR HAVE LEGAL SOLE CUSTODY / PLACEMENT, PLEASE PROVIDE OUR RECEPTIONIST WITH THE LEGAL DOCUMENTATION IN CORESPONDENCE TO THESE CHANGES.

Add new row

PATIENT WAS REFERRED BY TO PEDIATRIC ASSOCIATES BY

I the undersigned hereby agree to be responsible for all charges and I understand that payment is to be made at the time service is rendered unless other arrangements are made. If insurance billed, I agree to all payments being made directly to the provider, Samir Mullick M.D., S.C.

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 / Guardian's Signature

Date

PLEASE OFFER INSURANCE CARD TO OUR RECEPTIONIST. IT IS THE RESPONSIBILITY OF THE PARENT /GUARDIAN TO INFORM THIS OFFICE OF ANY CHANGES IN THE ABOVE INFORMATION.

*Do you have other children who are patients of Pediatric Associates? (If yes, please list below)

Yes No

Add Additional Name

FINANCIAL RESPONSIBILITY CONTRACT

parent/ guardian of

Date of Birth

understand and agree That the services have been rendered for which I am fully responsible, whether or not medical or other Insurance should cover the cost of at least a portion of the services rendered.

I further understand and agree that In the event that I default on any payments due and owing this practice for such service, I will pay any and all costs of collection of such payments due and owing, including, without limitation, reasonable attorney's fees, 3rd party collection agency fees, court cost, and other such 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.

Parent / Guardian's Signature

Date

PRIVACY NOTICE ACKNOWLEGEMENT

The signature below acknowledges a copy of this Notice was RECEIVED (not necessarily read).

Date

Patient/Legal Representative Signature

State Capacity, if Legal Representative

FOR INTERNAL USE ONLY

Lack of Patient Acknowledgement

Date

Reason

Staff Signature

Patient's Name

Date of Birth

SSN No.

AUTHORIZATION TO DISCLOSE HEALTHCARE INFORMATION

Below is a list of persons that you give permission for our clinic to discuss and use the patient's protected health information, including condition and treatment plan, test results, prescriptions, X-rays:

Add Additional Name

AUTHORIZATION TO TREAT MY CHILD

Below is a list of persons that you give permission for our clinic to treat your child when they are brought in by someone other than a parent or a guardian.

Add Additional Name

I understand that it is my responsibility to update this list in order to keep accurate those authorized persons to receive or use this patient's healthcare information.

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.

Patient Signature/Legal Representative

Date

If legal representative, explain the capacity

AUTHORIZATION FOR RELEASE (DISCLOSURE) OF PATIENT(S) HEALTH INFORMATION

Patient's Information

Add Additional Name

Address

City

State

Zip Code

Information Released (Choose One)

FROM

Physicians Office / Agency Name

Address

City

State

Zip Code

Telephone No.

Fax No.

Type of information to be Released

All my health information, including information relating to medical, pharmacy, dental, vision, mental health, substance abuse, HIV/AIDS, psychotherapy, reproductive, communicable disease and health care program information.

Surgeries

Physical(s)

Test Results

Pre-Op(s)

Vaccine Records

Progress Notes

Other

If other, please specify

Reason for Disclosure:

Transfer of Care

Insurance Change

Legal Use

Personal Use

Relocation

I understand and agree that:

This authorization is voluntary;
My health information may contain information created by other persons or entities including health care providers and may contain medical, pharmacy, dental, vision, mental health, substance abuse, HIV/AIDS, psychotherapy, reproductive, communicable disease and health care program information;
I may not be denied treatment, payment for health care services, or enrollment or eligibility for health care benefits if I do not sign this form except (1) if my treatment is related to research, or (2) health care services are provided to me solely for the purpose of creating protected health information for disclosure to a third party;
My health information may be subject to re-disclosure by the recipient, and if the recipient is not a health plan or health care provider, the information may no longer be protected by the federal privacy regulations;
This authorization will expire one year from the date I sign the authorization. I may revoke this authorization at any time by notifying in writing; however, the revocation will not have an effect on any actions taken prior to the date my revocation is received and processed.

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.

Patient/ Legal Guardian Signature

Relationship to Patient

Date

PARENT/GUARDIAN CONSENT FORM

Note: A signed parent consent form lasts until the child turns 18 unless withdrawn, If the consent form is not returned, anyone under 18 will not be able to receive general medical services, however confidential reproductive health services are available by state law.

Adolescents under age 18 must have a signed parent/guardian consent form on file to receive some general medical services (including vaccines unless otherwise stated), *According to state law, parental consent is NOT required for pregnancy and contraceptive services, chemical abuse assessment and counseling, or diagnosis/testing and treatment of sexually transmitted infections. If you have any concerns regarding this consent please contact the office.

My teen has permission to receive medical service at Pediatric Associates.

I authorized vaccines to be giving to my child if she/he due or behind on Immunizations.

If applicable, I give permission to bill my health insurance carrier or Medicaid for general medical services received. (This would also apply if you do not have currently have Insurance but get it later)

I have received the notice of privacy practices stating I may have access to my child's general medical records but NOT to any confidential services provided as stated in the Wisconsin Statute 51.30

I understand I will be notified in case of emergency or very urgent need for. follow up medical care

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

Date of Birth

Parent / Guardian Signature

Today's Date

Your information will be encrypted.