Patient Newborn Registration

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      INSURANCE

      Primary Insurance

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        Add Additional Siblings

        Tricare

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          Add Additional Siblings

          Secondary Insurance

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            Add Additional Siblings

            Family History (Please click Yes or No and explain if indicated)

            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.

            Acknowledgement of Notification of Privacy Policies (HIPAA)

            To better serve our patients, we have revised our policy notice effective October 1, 2017.

            PRIVACY POLICIES ACKNOWLEDGEMENT OF RECEIPT (HIPPA)

            I have read a copy of Jenny Welham, MD LLC's Notice of Privacy Policies with the effective date of July 1, 2016. If you would like a copy of the Notice of Privacy Policies, you may ask the receptionist at the front desk.

            INFORMATION UPDATE

            Upon checking in, please inform the office staff of any changes to your information (address, phone numbers, insurance, etc.) Any charges incurred to your account will be your responsibility if you do not inform us of any changes

            VACCINE ADMINISTRATION

            I have been provided a copy of the appropriate Vaccine Information Statement (V.I.S) prepared by the Center for Disease Control, and have read, or have explained to me, information about the diseases and the vaccine cited. I have had the chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of this vaccine, and ask that it be given to the person named below (for whom I am authorized to make this request).

            FORMS AND MEDICATION REFILLS

            Please give a minimum of 2 business days notice for completion of any medical forms/school forms/letters and requests for medication refills.

            APPOINTMENT "NO SHOWS" AND CANCELLATIONS

            There is a $25.00 fee per patient for any "No Show" or cancellation of visits with less than 24 hours of notice.

            COPIES OF MEDICAL RECORDS

            There is a $40.00 fee for release of personal copies of medical records. If medical records are being requested directly from another physician's office, there is no fee.

            PAYMENTS ON ACCOUNTS

            I have read a copy of Jenny Welham, MD LLC's Office Payment Policy with the effective date of July 1, 2016.We accept cash, check and credit card payments. Please make checks payable to Jenny Welham, MD LLC. Payment is due in full prior to services rendered if you have no insurance and/or if your visit is not a covered benefit of your insurance plan.

            I hereby authorize the release of medical information to my insurance carriers concerning my illness and treatment and hereby assign all payments for medical services to my doctor. I understand I am responsible for payment of any amount not covered by my insurance.

            I understand all of the information that has been provided to me as stated 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.

            Your information will be encrypted.

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