Patient Registration Form

Date

Patient Information

Last Name:

First Name:

Middle Name:

Date of Birth:

Age:

Sex:

SS#:

Race

African-American Caucasian Other Decline to Respond

Ethnicity

African-American Caucasian Hispanic Other Decline to Respond

Insurance Information

Primary Insurance Company Name:

Policy Number:

Group Number:

Policy Holder Name:

DOB:

Relationship to Patient:

Upload Photo of Insurance Card

Add file

Please upload a file

Secondary Insurance Company Name:

Policy Number:

Group Number:

Policy Holder Name:

DOB:

Relationship to Patient:

Upload Photo of Insurance Card

Add file

Please upload a file

Mother/Legal Guardian

Name:

Address

Home Phone:

Cellphone:

Email:

DOB:

SS#:

Marital Status

Single Married Divorced Widowed

Father/Legal Guardian

Name:

Address:

Home Phone:

Cellphone:

Email:

DOB:

SS#:

Marital Status

Single Married Divorced Widowed

Who is the primary caregiver?

Both Mother Father Other

If applicable, who has primary custody?

Both Mother Father

Other (Please provide legal documents for any alternative custody arrangements.)

Emergency Contact (Other than Parent)

Name:

Relationship:

Home Phone:

Cellphone:

PLEASE LIST ALL PERSONS WHO MAY SCHEDULE APPOINTMENTS, CALLS FOR MEDICAL ADVICE OR BRING YOUR CHILD TO THE OFFICE FOR TREATMENT (I.E GRANDPARENTS, BABYSITTER, AUNT). THESE INDIVIDUALS WILL BE ASKED TO PRESENT IDENTIFICATION AT THE TIME OF VISIT. IF SOMEONE OTHER THAN THESE PERSONS CONTACTS US RELATIVE TO YOUR CHILD, WE WILL CONTACT THE PARENTS OR GUARDIAN FOR PERMISSION TO TREAT OR ADVISE. IN THE EVENT OF AN EMERGENCY, WE WILL TREAT AND MAKE EVERY ATTEMPT TO CONTACT THE PARENT OR GUARDIAN.

NAME:

RELATIONSHIP:

PHONE NUMBER:

Add New Contact Person

Additional Information

Preferred Language:

Preferred Provider:

Pharmacy Name:

Pharmacy Phone Number:

Pharmacy Address:

Authorization

As a courtesy, Pediatric Care Center will verify and file insurance, but the practice cannot guarantee payment, I understand that I am financially responsible for service rendered as and when charges are incurred. I hereby authorize Pediatric Care Center and/or the rendering physician(s) to release all medical information required by insurance company to file claims for medical benefits. I authorize payment of all applicable benefits directly to Pediatric Care Center.

Uses of Protected Health Information to Contact You

We may use your protected health information to contact you by phone or via e-mail at any other location that you may specify and leave a message regarding appointment reminders, insurance items and any calls pertaining to your child's clinical care, including lab and x-ray results with information about treatment alternatives or other health related benefits and services that in our opinion may be of interest to you.
This authorization will remain in effect until revoked by me in writing. A photocopy is to be considered as valid as the original.
Consent to release information acquired in the course of examination and/or treatment in regards to treatments, payments or services and operations is understood and explained to you in the Notice of Privacy Practices.

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

Parent/Guardian Signature

Date

Written Authorization to obtain Immunization

We, the parents/legal guardian(s) of (Please List Child's Name)

(Name of minor child)

Name of Parent(s)/Guardian(s)

Provide consent to Pediatric Care Center for immunization of out\my minor\children.

I do hereby request and authorize the medical staff to perform necessary medical services including immunization for the child\children named above.

I\we understand that this written authorization may be withdrawn at any time by providing notice in writing. The notice of withdrawal must be given to the person authorized above and to any health care provider who has given a copy of this written authorization.

This Consent is given on

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

Signed: Parent(s)\Legal Guardian(s)

Date:

Witnessed:

Date:

Financial Policy

Thank you for choosing Pediatric Care Center as the health care provider for your child. Our practice is committed to providing the highest level of quality care. It is extremely important to our professional relationship that you have a clear understanding of our financial policy and your responsibility in helping us to maintain the terms of our policy. Pediatric Care Center has adopted the following financial policy. Please take a moment to read and sign as a validation that you understand the terms as outlined.

Contracted Insurance Co-Payment/Co-Insurance/Deductible

Pediatric Care Center participates with most of the insurances that are contracted with VI Equicare Inc., and will file all charges incurred with the appropriate claims office. We have agreed to accept the rates from these plans, however, all co-Insurance and co-payments are your responsibility and are payable at the time of service as per your contractual obligation with your insurance company. Pediatric Care Center is contractually obligated and will collect the co-payments prior to each visit with your doctor.

The cost of billing co-payments often exceeds the co-payment amount, therefore, you will be charged a $10 processing fee if you are unable to pay your co-payment at the time of service. Pediatric Care Center will collect in full any amount incurred per visit until your deductible has been met.

Today's health insurance policies and coverages offer more options than ever. Each patient is responsible for knowing his/her plan benefits package, co-payments, co-insurance, deductible, non-covered services and restrictions.

Newborns

Newborns are usually covered by the mother's or father's insurance for the first 30 days of life. The baby must be added to the insurance policy as soon as possible within the first 30 days of life for insurance to continue for your child. If you are unable to present a card or we are unable to verify coverage after your child is 30 days, you will be asked to pay in full unless we can ascertain coverage.

Non-Contracted Insurances

If we do not participate with your insurance plan, payment in full is expected at the time of service. If you choose, we can submit a claim form to your insurance company as a courtesy to you.

Secondary Insurance

Having more than one insurer DOES NOT necessarily mean that your services are covered 100%. Secondary Insurers will pay a fraction of what your primary carrier pays. We also will bill your secondary carrier as a courtesy. You are however, responsible for any balances after your insurances have not covered.

Hospital Visits

A claim will be submitted to your insurance company following the hospital discharge of your child. Any balance remaining will be due after receipt of payment and/or explanation of benefits from your insurance company.

No Insurance

Full payment is due at the time of service. If you are unable to pay your balance in full, please make arrangements with our billing department. Failure to make prior arrangements will result in additional fees due to the cost of processing the bills.

Payment/Service Charges

We accept cash, credit cards (VISA or MasterCard), or debit cards (with or without logo).
In the event that there are any outstanding payments after service there will be a service charge fee of $10.00 if payment is not made by the end of the business day.
There will be a $25 service charge for all returned checks.
Any outstanding balances are due within 30 days. If you experience circumstances out of your control, please call our office and we will be happy to establish payment arrangements with you. All accounts with unpaid balances or 60 days will be assessed a $15.00 monthly statement fee. All balances over 90 days past due will be sent to a collections agency. Should your account be sent to a collection agency, you will be financially responsible for any collection fees and fess that this office incurs throughout the process utilized to collect the delinquent balance.

ADDENDUM

NO SHOW AND LATE CANCELLATION FEE FOR SPECIALTY SERVICES

Since we attempt to schedule patient appointments as quickly as possible, it is very important that patients keep their appointments or give us at least 24-hour notice if they must cancel or reschedule. This will give other patients the opportunity to schedule needed appointments. This serves to notify you that we have adopted a No-show/Late Cancellation Fee of $60.00 if you do not show up for the appointment or do not provide us at least a 24-hour notice to cancel your child's appointments. This applies to all specialty services offered at Pediatric Care Center (Enhanced Asthma Visits, Behavioral Pediatric Services and Pediatric Neurology Consultations).

Patient Name:

Date of Birth:

Add New Patient Name

Parent/Legal Guardian:

Date:

Thank you for upholding our financial policy. If you have any questions or concerns, please contact our billing department.

Patient Acknowledgement of Receipt of Notice of Privacy Practices

I, (Please State Name below), hereby acknowledge that I have reviewed and received a copy of this office's Notice of Privacy Practices explaining:

Name:

How this office will use and disclose my protected health Information.
My privacy rights with regard to my protected health information.
This office's obligations concerning the use and disclosure of my protected health information.

I understand that the Notice of Privacy Practices may be revised from time to time and that I am entitled to receive a copy of any revised Notice of Privacy Practices upon request.

I also understand that if I have any questions or complains, I may contact
Sharon Ricketts
4504 Estate Diamond, Suite 3
Christiansted, VI 00820
Tel: (340)719-0681

You may also contact the Secretary of the U.S. Department of Health and Human Services with any concerns regarding our privacy and security procedures.

Patient or Personal Representative

Name:

Relationship to Patient:

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:

Your information will be encrypted.