Patient Packet

PEDI MED CENTER

Please correct the errors described below.

MOTHER OR LEGAL GUARDIAN

FATHER OR LEGAL GUARDIAN

In Case of Emergency (Friend or Relative not listed above)

INSURANCE INFORMATION (A copy of ALL Insurance cards is required for filing purposes.)

Your receipt for each visit will contain all the information needed to process an insurance claim. Please remember that insurance is a method of reimbursing you for fees paid to the doctor and is not a substitute for payment. I hereby assign to Sari Nabulsi, MD, LTD, LLP all payments for medical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by insurance. The above registration information is correct to the best of my knowledge and I understand and accept the above payment policy. I hereby authorize Sari Nabulsi, MD, LTD, LLP to release any pertinent medical information to my insurance carriers for myself or dependents. 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.

CONSENT FOR TREATEMENT

I hereby apply for treatment at Pedi Med Center and give permission for any attending physician or non-physician provider (PA, CFNP or CPNP) of the Pedi Med Center staff, and for any consultant or assistant who he or she may call to his or her aide, to administer treatment and/or medication deemed necessary for the care and treatment of my child. I authorize the employees of Pedi Med Center to assist my physician/non-physician provider in any way deemed necessary for such treatment. 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.

LETTER OF GUARANTY

2. Guarantor is making this guaranty in exchange for one of the Providers from Sari Nabulsi, MD, LTD, LLP providing medical services to Guarantor’s child. 3. Guarantor accepts and understands that all charges incurred in the treatment of the Guarantor’s child shall be the sole responsibility of the Guarantor. 4. Guarantor shall be responsible for all medical services and charges incurred for same if child gets married, is no longer covered by Guarantor’s insurance, reaches the age of majority, no longer resides with Guarantor, or any other situation. 5. Guarantor is guaranteeing that he/she will provide payment for all services rendered and charges incurred in the treatment of the child. 6. Guarantor understands THAT NEITHER ANY OF THE PROVIDERS OF SARI NABULSI MD, LTD, LLP NOR ANY OF ITS AGENTS, EMPLOYEES OR OTHER STAFF WILL AT ANY TIME FILE THE CHARGES INCURRED IN THE TREATMENT OF GUARANTOR’S CHILD WITH MEDICAID. 7. Guarantor understands that he/she is requesting PRIVATE PAY rather than MEDICAID and as such, will be solely and fully responsible for the entirety of any charges incurred by the child for whom the Guarantor is guaranteeing this payment. 8. Payment for all services rendered to Guarantor’s child shall be made at such time as services are rendered. 9. This guarantee may only be amended or modified in writing. This guaranty may not be amended or modified orally. 10. This letter of Guaranty shall be construed under and in accordance with the laws of the State of Texas, and all obligations of the parties created in this agreement are performable in Midland, Midland County, Texas. Payment in full for all services rendered under this agreement is expected at the time such services are rendered. 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.

PATIENT RECORD OF DISCLOSURES

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of protected health information (PHI). The individual is also provided the right to request confidential communications of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of their home.

I wish to be contacted in the following manner (check all that apply)

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.

The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to use of disclosures made pursuant to an authorization requested by the individual. Healthcare entities must keep records of PHI disclosures. Information provided below, if completed properly, will constitute an adequate record.

Record of Disclosures of Protected Health Information

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PEDIATRIC INTAKE FORM

Our practice is dedicated to providing the best possible care for your child. In order for us to serve you better, please take a few minutes to answer the following questions. Your answers will be kept stricktly confidential as a part of your child's medical record. Ongoing evaluations of our care may involve chart reviews by qualified persons, but neither your name nor your child's name will ever appear in any reports.

FAMILY MEDICAL HISTORY

Does the child's mother, father or grandparents have any of the following, if yes, who?

FAMILY SAFETY

WHEN YOU WERE A CHILD

TB/CHOLESTROL RISK ASSESSMENT

DRINKING AND DRUGS

I hereby authorize (when I am unavailable to give consent) to the following individuals(s):

Add another authorized person

to consent to any and all medical care and attention for this child which is deemed necessary and appropriate by a healthcare provider licensed in the State of Texas. This consent includes, but not limited to, medical and surgical intervention and elective as well as emergency care. This delegation shall be valid until I withdraw delegation of consent in writing. 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.

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