Patient Registration Form

Patient Information

Add Additional Child

INSURANCE INFORMATION

Primary Policy

Policy Holder's Name:

Policy Holder's Birth Date:

Policy Holder's Sex:

Male Female

Insurance Carrier:

Policy ID#:

Group #:

Secondary Policy

Policy Holder's Name:

Policy Holder's Birth Date:

Policy Holder's Sex:

Male Female

Insurance Carrier:

Policy ID#:

Group #:

IF INSURANCE INFO IS DIFFERENT THAN FIRST CHILD, PLEASE NOTIFY STAFF

Contact Information

Name:

Relation to Patient:

Home Phone

Cell Phone:

Preferred Email

Mailing Address:

City:

State:

Zip Code:

Please note cellphone will be used as default contact number for calls and appointment reminders.

Additional Contact Questions:

Who should receive billing statements?

If address different thant above please note:

If parents are divorced or separated, please fill out this section:

Who has custody?

Are there any legal restriction that would restrict the non-custodial parent from consenting to medical treatment for the child or from obtaining information about the child's medical treatment?

Yes No

If Yes, please explain and provide a copy of any legal paperwork that supports this restriction.

Click here to upload file for the legal paperwork that supports this restrictions.

Add file

Please upload a file

Assignment of Benefits:

I understand that I am responsible for the accuracy of the information I have provided on this form. I authorize payment of medical benefits directly to Bucci Lancer Pediatrics, LLC for all services rendered. I authorize the release of any medical and/or additional information necessary for the processing of claims. If for any reason payment is not be made by my insurance carrier. I will be responsible for all fees incurred with Bucci Lancer Pediatrics, LLC as well as late fees for unpaid balances and all costs associated with collection agencies and/or attorney fees. I acknowledge that I have reviewed the Practice's HIPAA Notice of Privacy Practices and a copy will be provided to me at my request.

I understand that the parent/Guarantor who brings the child to the office for medical services is responsible at the time of service for co-payments, deductibles, balances and for payment in full for services that are not covered by insurance.

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.

Guarantor Name:

Relationship:

Second Guarantor Name:

Relationship:

INTERVAL HISTORY INFORMATION

Allergy / Reaction Information

Medication Allergies If Yes, Explain Below

Yes No

Add another medication allergy

Non-Medication Allergies

None Yes

If yes, please list

Vaccine Reactions:

None Yes

If yes, please list

Current Medications

Add another medication

Current Problem List (i.e Asthma, Migraine, etc.)

Add another problem

Pertinent Past Medical History (Check if Yes and Provide details)

Serious Injuries

Surgeries

Hospitalizations

Pertinent Family Medical History

if positive family history - Please select whom (paternal vs maternal)

Allergies

Asthma

Lung Disease

Cancer

High Blood Pressure

High Cholesterol

Diabetes (Type I and II)

Headache/Migraine

Seizure Disorder

Neurologic Disorder

Heart Disease (Less that 55yo)

Autoimmune Disorder

Gastrointestinal Disease

Blood Disorder (i.e sickle cell/thalasemia)

Mental Illness

Birth Defects

Hearing Loss

Kidney Disease

Thyroid Disease

Learning Problems

Pertinent Social History

Who lives in the home (Information used to link patient accounts - if siblings listed previously, please do not include below).

Add another

Guns in Home?

Yes No

If yes, Are guns in a locked safe?

Yes No

Tobacco Exposure

Yes No

Pets

Yes No

HIPPA Notice of Privacy Practices

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. The HIPAA Notice of Privacy Practices describes how we can disclose your protected health information (PHI) ot carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health care information. "Protected health information" is information about you, including demographics, that may identify you and related to your past, present or future physical or mental health or condition and related health care services.

Signature below is only recognition that you agree, for all children listed, to the HIPAA Notice of Privacy Practice. A copy of the document will be provided to you upon request.

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.

Name:

Signature:

Date:

Policies & Procedures:

Form 03082017 (Bucci Lancer Pediatrics Office Policies and Procedures) summarizes the Practice's protocol on matters related to insurance, cancellations, vaccine schedules, and other pertinent office information. A copy is available for you to review in the front office and on our website: buccilancermd.com. A copy of the document (Form 03082017) will also be provided to you upon request.

Signature below indicates that you fully understand and agree to the office and finacial policies set forth by the practice, for each child listed above. The Practice may amend the terms fo these policies at any time without prior notification.

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:

Date:

Your information will be encrypted.