Demographic Form

Patient Demographics Information

Responsible Party Information - Guardian(s)

Emergency Contact Information

OPTIONAL Demographics Information

Insurance Information - Guarantor

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.

I ACKNOWLEDGE THAT THE OFFICE OF JULIE TOMBERLIN MD PA DOES NOT ACCEPT PATIENTS WHO CARRY MEDICAID AS PRIMARY OR SECONDARY COVERAGE. AS THE OFFICE IS NOT IN NETWORK WITH MEDICAID, WE ARE UNABLE TO APPROPRIATELY FILE CLAIMS FOR PATIENTS WITH THIS COVERAGE. IF YOUR CHILD HAS MEDICAID COVERAGE, EVEN IF IT IS NOT THE PRIMARY COVERAGE, WE WILL NOT BE ABLE TO ESTABLISH CARE FOR THEM.

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.

Records Needed

Record Release Form

Request for Records Release to Julie Tomberlin MD PA

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

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.

Late, Cancellation and NO SHOW POLICY

In an effort to give everyone the full attention they deserve, we ask that our families help us by arriving ten minutes prior to their appointment time. This allows us to have all the check in and vitals completed so that you are ready to be seen by your scheduled appointment time. We have the following policies in place regarding late arrival, late cancellation, and missed appointments.

LATE

If you arrive after your scheduled appointment time, we will need to reschedule your appointment and a $25 late arrival fee will be charged.

NO SHOW

If your scheduled appointment is missed, you will be charged $50 for missed sick or follow up appointments and $100 for a missed well check or behavioral health appointment. Initial Behavioral Health appointments missed or late canceled will be a $200 fee.

We will dismiss your family if there are 3 missed appointments for the family.

Well check and Behavioral Health appointment forms must be completed at least one day prior to your scheduled appointment. If they are not completed within the required time frame, your appointment will be canceled and a $100 no show fee will apply.

New patients who miss their first scheduled appointment will not be eligible for establishment with our practice.

LATE CANCELLATIONS

An appointment that is canceled less than 24 hours prior to the scheduled appointment time will be charged a $25 fee.

If you make a sick appointment for the same day and then decide to cancel it, we require notice within 1 hour of setting the appointment (i.e. you called at 9 am, we would need to hear from you by 10 am in order to avoid a late cancellation fee).

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

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.

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)

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.

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.

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.

Notice of Privacy Practices Acknowledgement

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.

Nurse Practitioner Consent Form

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, Christina Bates, and Kim Settle. Nurse Practitioner staff is subject to change.

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.

Well Child Policy

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.

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 AND UNDERSTAND THE TERMS AND CONDITIONS OF THE FOLLOWING POLICIES (DETAILED ABOVE):
-Confidential Communication Request
-Late, Cancellation and NO SHOW POLICY
-Financial Policy and Patient Consent
-Billing Summary / Benefits Policy
-Patient Consent for Disclosure of Information
-Notice of Privacy Practices
-Nurse Practitioner Consent Form
-Well Child Policy

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.

Non-Guardian Adults Authorized to Accompany a Minor

There are no court orders currently in effect which would prohibit me from exercising the power that I now seek to convey.

In the event that I am absent and unable to provide consent at the time:

• I hereby consent to and authorize any urgent or emergency medical, dental, or diagnostic procedure and/or treatment, surgical care and/or hospitalization that my child(ren)’s health care provider determines, in his or her best judgment, is necessary for the health and well-being of my child(ren), including, but not limited to, provision of prescription and non-prescription medication.
  
  
• In my absence, I authorize my child(ren)’s health care provider to disclose my child(ren’s) medical information to the individual(s) designated below as necessary for such individual(s) to assist in the care of my child(ren).
  
  
• In my absence, I request that my child(ren)’s health care provider discuss my child(ren)’s health needs with the individual(s) designated below;
  
  
• In my absence, I authorize those persons, to the extent state law permits me to do so, to care for my child(ren) and to consent to recommended care and treatment for my child(ren).
  
  
• I designate the individual(s) on the following list, in the order of priority listed, to act on my behalf when I am not reasonably available to provide consent necessary for any non-urgent or non-emergency medical, dental, or diagnostic procedure and/or treatment for my child(ren):

In the event I cannot be reached in an emergent situation I authorize my child(ren)’s health care provider to act in the best interest and wellbeing of my child(ren).

To the extent I have authorized the above individual(s) to act on my behalf in my absence, I hereby release and hold harmless my child(ren)’s health care providers, including any physician, hospital or hospital personnel, or other health care provider rendering care to my child(ren), arising from the failure to obtain consent from me.