Demographic Form

Date

Patient's Last Name

First Name

Middle Initial

Birth Date

Sex

Male Female

Address

City

State

Zip

Primary Phone

Ok to Text?

Yes No

Secondary Phone

Ok to Text?

Yes No

Responsible Party Information

Father's Name

Birth Date

Father's Employer

Occupation

Work Phone #

Cell Phone #

Mother's Name

Birth Date

Mother's Employer

Occupation

Work Phone #

Cell Phone #

Emergency Contact

Relationship

Emergency Contact Phone #

Alternate Phone #

Referred By

Insurance Information

Primary Insurance Company

ID / Member #

Group #

Policy Holder's Name

Birth Date

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.

Signature of Patient/Guardian

Printed Name of Parent/Guardian

Printed Name of Patient

Date

Confidential Communication Request

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.

PLEASE INDICATE YOUR AGREEMENT BY MARKING ALL THAT APPLY. LEAVE BLANK ANY FOR WHICH YOU DO NOT GIVE CONSENT.

Detailed phone messages regarding my child may be left on the following numbers

Phone

Initials

Phone

Initials

Detailed text messages regarding my child may be sent to the following numbers

Phone

Initials

Phone

Initials

Detailed emails regarding my child may be sent to the following email address.

Initials

I give permission for Julie Tomberlin MD PA to give detailed information regarding my child to the following:

Name

Relationship

Phone

Name

Relationship

Phone

THE ABOVE PERMISSION WILL REMAIN IN EFFECT UNTIL RESCINDED IN WRITING.

Signature

Printed Name

Late, Cancellation and NO SHOW POLICY

LATE

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

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.

CANCELLATIONS

A $25 fee will be charged for each appointment that is cancelled within 24 hours of the appointment.

***Automated appointment reminders are a courtesy only and should not be relied upon for keeping your child’s appointment.

Signature of Parent/Guardian

Printed Name of Parent / Guardian

Printed Name of Patient:

Date

Financial Policy and Patient Consent Form

The following is provided to avoid any misunderstanding concerning payment for medical services.

1. Payment

Payment is expected at the time of service.
You are responsible for any balance after insurance processes your claim.
Any balance remaining after insurance processes the claim is billed to the responsible party indicated on the account. Accounts not paid in full after 90 days will be referred to an outside collection agency or paid using Credit Card on File information.

2. Managed Care

All managed care (HMO, PPO, etc.) copayment amounts are due at the time of service.
This office does not set copayment amounts.
This office collects $125 per visit for ALL plans with deductibles that apply to medical office visits. This is an ESTIMATE of the cost of the visit. Any balance will be billed and any overpayment will be credited to the account once the claim has been processed.

3. Children of Divorced Parents

The parent or guardian who brings the child for any visits is the responsible party.
Responsibility for payment for treatment of minor children whose parents are divorced rests with the parent who is in our office building at the time of treatment.
This parent is required to pay for services rendered regardless of what a divorce decree may state. Any court-ordered responsibility judgment must be determined between the individuals involved, without the inclusion of Julie Tomberlin MD PA

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.

Signature (Insured/Guardian)

Printed Name (Insured/Guardian)

Patient Name (Please Print)

Date

Billing Summary / Benefits Policy

Our office will accept an assignment of benefits from your insurance company with the following provisions:

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.

I HAVE READ AND UNDERSTAND THE ABOVE TERMS AND CONDITIONS. I AUTHORIZE MY INSURANCE COMPANY TO PAY MY HEALTH BENEFITS DIRECTLY TO THE OFFICE OF JULIE TOMBERLIN MD PA OR TEXAS HEALTH CARE PLLC (PRIVIA)

Signature of Parent/Guardian

Printed Name of Parent/Guardian

Printed Name of Patient

Date

Patient Consent for Disclosure of Information

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:

Sharing Information For Purpose Of Treatment: You will share information with all members of my treatment team, both within this office and with our providers (personal and institutional) in order to provide me with quality care and educational/wellness programs specified in my insurance plan;
Sharing Of Information For Purposes Of Payment: You will share all necessary information with my insurer(s), payor(s), governmental entities (such as Medicare, Medicaid, etc.) and their representatives involved in the billing process (including, but not limited to) claims representatives, data warehouses, billing companies;
Sharing Of Information For Purposes Of Operations: You will share all information necessary for ongoing operations of this office, including (but not limited to) the credentialing process, peer review, accreditation and compliance with all federal and state laws.

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.

Signature of Parent/Guardian

Printed Name of Parent/Guardian

Printed Name of Patient

Date

Record Release Form

Request for Records Release to Julie Tomberlin MD PA

Previous Physician's Name

Address

City

Zip

Phone

Fax

The following individual is requesting that his/her medical records be released and forwarded to our office at the address below:

Patient's Name

Birth Date

Address

Phone

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

Signature of Parent/Guardian

Printed Nme of Parent/Guardian

Printed Name of Patient

Date

Household

Please list all those living in the child's home

Name

Relationship to Child

Birth Date

Health Problems

Add another person living in the home

Are there any siblings not listed? if so, please list their names and ages and where they live.

Yes No

Add new row

If mother and father are not living together or if the child does not live with parents what is the child's custody status?

If one or both parents are not living in the home, how often does he/she see the parent/parents not living in the home?

Birth History

Birth Weight

Was the baby born

At Term? Early? Late?

If early, how many weeks gestation?

Did the mother have any illness or problem with her pregnancy?

Yes No

If yes, explain

During the pregnancy, did the mother Use Drugs or Medications?

Yes No

If yes, What and When?

During the pregnancy, did the mother Drink Alcohol?

Yes No

If yes, What and When?

During the pregnancy, did the mother Smoke?

Yes No

If yes, What and When?

Was the delivery

Yes No

If Cesarean, Why?

Did your baby have any problems right after birth?

Yes No

Explain

Was Initial Feeding

Breast Bottle

Explain

Did your baby go home with mother from the hospital?

Yes No

Explain

General

Do you consider your child to be in good health?

Yes No

Explain

Does your child have any serious illness or medical condition?

Yes No

Explain

Has your child had serious injuries or accidents?

Yes No

Explain

Has your child had any surgery?

Yes No

Explain

Has your child ever been hospitalized?

Yes No

Explain

Is your child allergic to any medicines or drugs?

Yes No

Explain

Development

Are you concerned about your child's physical development?

Yes No

Explain

Are you concerned about your child's mental or emotional development?

Yes No

Explain

Are you concerned about your child's attention span?

Yes No

Explain

If your Child is in School

How is your child's behavior in school?

Has he/she failed or repeated a grade in school?

How is he/she doing in academic subjects?

Is he/she in special or resource classes?

Family History

Has any family member had the following

Deafness

Yes No

Who?

Comments

Nasal Allergies

Yes No

Who?

Comments

Asthma

Yes No

Who?

Comments

Tuberculosis

Yes No

Who?

Comments

Heart Disease (before 50 years old)

Yes No

Who?

Comments

High Cholesterol

Yes No

Who?

Comments

Anemia

Yes No

Who?

Comments

Bleeding Disorder

Yes No

Who?

Comments

Liver Disease

Yes No

Who?

Comments

Kidney Disease

Yes No

Who?

Comments

Diabetes (before 50 years old)

Yes No

Who?

Comments

Bedwetting (After 10 years old)

Yes No

Who?

Comments

Epilepsy or convulsions

Yes No

Who?

Comments

Alcohol Abuse

Yes No

Who?

Comments

Drug Abuse

Yes No

Who?

Comments

Mental Illness

Yes No

Who?

Comments

Developmental Delay

Yes No

Who?

Comments

Immune Problems, HIV or AIDs

Yes No

Who?

Comments

Additional Family History?

Past History

Does your child have, or has he/she ever had

Chickenpox

Yes No

When?

Frequent Ear Infections

Yes No

When?

Problems with ears or hearing

Yes No

When?

Nasal Allergies

Yes No

When?

Problems with eyes or vision

Yes No

When?

Asthma, bronchitis, bronchiolitis, or pneumonia

Yes No

When?

Any heart problems or heart murmur

Yes No

When?

Anemia or bleeding problem

Yes No

When?

Blood Transfusion

Yes No

When?

Frequent Abdominal pain

Yes No

When?

Constipation requiring doctor visits

Yes No

When?

Bladder or kidney infection

Yes No

When?

Bedwetting (after 5 years old)

Yes No

When?

For girls: Has she started her menstrual periods?

Yes No

When?

Any Chronic skin problems (acne, eczema, etc)

Yes No

When?

Frequent Headaches

Yes No

When?

Convulsions or other neurological problems

Yes No

When?

Diabetes

Yes No

When?

Thyroid

Yes No

When?

Any other significant problems

Yes No

Explain

Use of alcohol or drugs

Yes No

When?

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.

Signature of Parent/Guardian

Printed Name of Parent/Guardian

Printed Name of Patient

Date

Notice of Privacy Practices Acknowledgement

Patient Name

Date of Birth:

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.

Patient Signature

Date

Personal Representative Signature (If applicable)

Relationship to Patient

Nurse Practitioner Consent Form

Patient Name

DOB

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.

Parent/Guardian Signature

Date

Well Child Policy

Patient's Name

Date of Birth

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:

Measurement of weight, height/length, head circumference (2yo and under), blood pressure (3yo and up)
Complete head-to-toe physical exam done by your provider (doctor or nurse practitioner)
Discussion with your provider about your child’s growth and nutrition/diet
Discussion with your provider about normal developmental milestones and your child’s progression in achieving these
Discussion with your provider about normal age-related development and safety topics
Discussion of sports-related screening questions for student athletes

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:

Standardized developmental surveys (PEDS, PEDS-DM, MCHAT done on Ipad)
Hemoglobin blood test
Vision screening
Hearing screening
Depression, Anxiety, ADHD, lead, and other standardized screening questionnaires

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.

Parent/Guardian Signature:

Date

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