CHILDREN OF DIVORCED PARENTS: Responsibility for payment for treatment of minor children whose parents are divorced rests with the parent who brings the child(ren) into the office. Any court ordered responsibility judgment must be determined between the individuals involved WITHOUT the inclusion of JULIE TOMBERLIN MD PA.
I have completed this form fully and certify that I am the patient or authorized agent of the patient, authorized to furnish all the information requested. I understand that even though I have insurance coverage, I am responsible for payment of services rendered. I hereby assign to the above named doctor/practice all benefits, rights and proceeds for services rendered under any insurance policies or any reimbursement or prepaid healthcare plans. I hereby authorize the release of pertinent information to insurance carriers and agree to pay all charges incurred.
DISCLAIMER: By typing your name below, you are signing this application electronically in agreement with the above policies and statements. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
In order to protect your child’s privacy, we need your written permission to leave detailed phone, email or text messages regarding your child, including messages that contain health and/or billing information. Please note that current Notice of Privacy Practices allows us to contact you without written approval with a courtesy reminder regarding upcoming appointments.
DISCLAIMER: By typing your name below, you are signing this application electronically in agreement with the above policies and statements. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
We will no longer see patients who arrive after their scheduled appointment time. In order to keep the appointments as on-time as possible, late arrival to an appointment will cause you to be rescheduled and charged a $25 fee
No show appointments will be charged $50 for each missed sick appointment and $100 for each missed well check appointment. Your child(ren) will be dismissed after the 3rd missed appointment for your family. We will not see new patients who no show their first appointment.
A $25 fee will be charged for each appointment that is cancelled within 24 hours of the appointment.
DISCLAIMER: By typing your name below, you are signing this application electronically in agreement with the above policies and statements. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
The following is provided to avoid any misunderstanding concerning payment for medical services.
It is our hope that the above policies will allow us to provide the highest quality care to our patients. If you have any questions or need clarification regarding these policies, please call us at (682) 518-8111.
Disclaimer: 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.
1. Filing claims through insurance does not eliminate the financial obligation for the medical service my child or I have received.
2. Copay, deductible and coinsurance amounts are due in full at the time of service. We do not waive collection of these fees in exchange for medical services. Payment of any remaining balance is due after your insurance company processes the claim or as provided below.
3. If we have not received payment after 90 days, we will charge the credit card we have on file OR we will forward the balance to a third-party collection agency.
4. If your claim is denied, you will be responsible for paying the self-pay or cash balance plus full cost of all medical supplies.
5. Our office will NOT enter into a dispute with your insurance company for any claim, although we will provide necessary documentation your insurance company requests to sort out any confusion or questions that may arise. We will cooperate fully with the regulations and requests of your insurance company. It is ultimately your responsibility to resolve any type of dispute over payments made or not made by your insurance company.
DISCLAIMER: By typing your name below, you are signing this application electronically in agreement with the above policies and statements. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
I have read the Notice of Privacy Practices and have had any questions answered by this office. I understand that by signing this form, I consent to the following:
My consent is freely given. I understand that I may revoke this consent at any time if that revocation is in writing, but any disclosures given in reliance on this prior consent will be permissible.
DISCLAIMER: By typing your name below, you are signing this application electronically in agreement with the above policies and statements. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
I hereby authorize the release of all necessary medical records to:
Julie Tomberlin MD PA
706 Hunters Row Ct.
Mansfield, TX 76063
Phone: 682-518-8111 / Fax: 682-518-8112
office@jt-md.net
DISCLAIMER: By typing your name below, you are signing this application electronically in agreement with the above policies and statements. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Please list all those living in the child's home
Has any family member had the following
Does your child have, or has he/she ever had
Disclaimer: 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.
I acknowledge that Julie Tomberlin MD PA has made available to me a copy of the practice’s Notice of Privacy Practices, which is at the front desk.
I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions.
DISCLAIMER: By typing your name below, you are signing this application electronically in agreement with the above policies and statements. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Julie Tomberlin MD PA has on staff advanced practice nurses (Nurse Practitioners) to assist in the delivery of pediatric medical care. Our Nurse Practitioners are Amanda Davis, Mindy Rhodes, and Kelti Haley.
An advanced practice nurse is not a doctor. An advanced practice nurse is a registered nurse who has received advanced education and training in the provision of health care. An advanced practice nurse can diagnose, treat, and monitor common acute and chronic diseases as well as provide health maintenance care. In addition, the advanced practice nurse may treat minor lacerations and other minor injuries
I have read the above, and hereby consent to the services of an advanced practice nurse for my child’s healthcare needs.
I understand that at any time I can refuse to see the advanced practice nurse and request to see the doctor, subject to availability.
DISCLAIMER: By typing your name below, you are signing this application electronically in agreement with the above policies and statements. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
The well child visit is an opportunity to discuss your child’s growth and development and discuss important age-related safety and behavior topics. This visit also allows us to do a complete physical exam so we can identify medical problems that may not be readily apparent without a thorough physical exam. The purpose of your child’s visit is what is called “preventative care” – looking for and discussing issues that may affect your child’s growth, development, and general well-being so we can identify and prevent smaller issues from progressing into larger problems.
Things that are included in your child’s well visit:
If needed, your child will receive immunizations (shots) at the well child visit. Please note that these are billed separately to your insurance company. As a courtesy, we verify insurance eligibility for these shots prior to your child’s visit. We, however, have limited access to coverage and benefit information, and you are ultimately responsible for knowing your plan limitations. If the immunizations are not covered by insurance, you will receive a bill from our office.
In addition to the above, many of our visits include other screening or preventative care. These are billed separately to your insurance company and may or may not be covered under your insurance plan. Rest assured that our recommendations for these services are made because they are a part of the American Academy of Pediatrics’ Bright Futures Guidelines. These guidelines are the gold standard of care in pediatrics and are important to identifying any issues EARLY before they become larger problems. Most, but not all, insurance companies pay for services recommended under these guidelines. The following are a list of some of the items that fall into this group:
Please also note that well child care does not include care of other chronic medical conditions (asthma, ADHD, allergies, mental health issues) or acute illnesses (ear infections, strep throat, gastrointestinal illnesses, etc.) that occur at the same time as the well visit. If we evaluate and treat chronic or acute conditions during the course of the well visit, we are mandated by your insurance company to document and bill separately for those issues. As such, you may be required to pay a copay. Please know that this is required by the insurance companies and we are forced to comply with this policy, as failure to do so would constitute insurance fraud.
It is our office policy that all patients have an annual well child exam (more frequently for children under 4yo). Failure to comply with this policy may result in dismissal from our practice.
I acknowledge I have read and understand the above policy. I agree I am responsible for any and all charges deemed to be my responsibility by my insurance carrier. These include, but are not limited to, copays, deductibles, coinsurance, benefits, and any services not covered by my insurance carrier.
DISCLAIMER: By typing your name below, you are signing this application electronically in agreement with the above policies and statements. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.