Patient Registration Form

Patient's First Name

Middle

Last Name

Patient's Address

City

State

Zip

Date of Birth

Home Phone

Social Security Number

Employer Name

Employer Address

Employer's Phone

Secondary Address

Dates there

Home Phone

IF PATIENT IS A DEPENDENT, GIVE GUARDIAN /PARENT INFORMATION

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INSURANCE INFORMATION

Add new row

PERSON TO NOTIFY IN CASE OF EMERGENCY

Name

Relationship to Patient

Home Number

Work Number

Cell Phone

OTHER FAMILY PHYSICIAN OR PEDIATRICIAN

Name

Phone Number

Address

City

State

Zip

REFERRING PHYSICIAN

Name

Phone Number

Address

City

State

Zip

CHILD HEALTH HISTORY

Name

Date of Birth

ALLERGIES

Add Additional Allergies

CURRENT MEDICATIONS

Add Additional Medications

PRENATAL AND DELIVERY HISTORY

Mother's age at pregnancy

Illness during pregnancy

Meds During Pregnancy

Birth Weight

Apgar

Type of Delivery

Where Delivered

Complications

FAMILY HISTORY

GROWTH & DEVELOPMENT (Please indicate Age)

PHYSICIAL

Add more Physical Developments

SOCIAL

Add more Social Developments

Add more Communication Developments

SOCIAL BEHAVIOR

Primary Language

Translation / Hearing Impaired Needs

Grade in School

Performance in School

AGES 8 YEARS AND UP

If yes, No. of Years?

Amount / Day / Week

PAST HISTORY

Age Performed

Files

Add file

Please upload a file

TUBERCULOSIS SCREENING

Do you or any member of your family or close contact have tuberculosis?

Yes No

Contact with persons in jail/prison in past 5 years?

Yes No

Have you or any member of your family or close contact traveled outside the country?

Yes No

Frequently (Every 2-3 years) exposed to the following (Check all that apply)

HIV+ Persons

Homeless persons

Residents of nursing homes

Institutionalized persons

IV / Street drug users

None

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Signature

Date

Nurse / Doctor Signature

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Allowed Uses and Disclosures of Your Medical Information:

Treatment -such as ordering diagnostic tests,
Payment -such as submitting billing information to your insurance company, and
Health Care Operations -such as quality assurance review, coordination of care, eligibility verification.

In addition to the above, your medical information may be used or disclosed for emergency treatment; when we are required by law to treat you, we attempt to obtain consent, and are unable to do so; we are unable to obtain consent due to substantial communication barriers and consent for treatment is implied under the circumstances; or we created or received the information in treating an inmate.

You have a right to:

Request restriction on certain uses and disclosures, however, we are not required to agree to any requested restriction.
Receive confidential communications from us, upon written request.
Inspect and request copies of your medical information.
Request to amend incorrect or incomplete medical information.
Receive an accounting of any disclosures made, upon written request.
Receive a paper copy of the notice upon request.

We are responsible for:

Maintaining the privacy of your medical information.
Providing you this notice.
Abiding by the terms of this notice.
Providing written notice of any change to this notice.

Complaints:

You may complain to us or to the Health & Human Services secretary if you believe that your privacy has been violated. If you wish to file a complaint with us, please provide the office manager with written notice of how you believe us. violated your privacy. All notices receiived will be investigated and reviewed by a physician. We will respond to all notices within two (2) weeks, and we will not retaliate for any allegations you make.

Authorizations:

Upon your authorization, we may disclose your medical information to a requesting entity, such as an attorney, another provider, or a relative. You may revoke any authorization you make at any time, except to the extent that it was already relied on.

Patient contact:

We may contact you to provide appointment reminders, treatment information, or for patient satisfaction surveys.

To obtain information. contact our office manager at 813-677-2222 (Tampa) or 813-677-2222 (Riverview).

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Parent/ Guardian Signature

Date

IMPORTANT INFORMATION REGARDING YOUR ACCOUNT

STATEMENT OF FINANCIAL RESPONSIBILITY

I understand that I am responsible for the payment of this account, and hereby assume and guarantee prompt payment of all expenses incurred.

NOTICE OF "NON-COVERED" SERVICES

I am aware that some services performed by Children's Health Center may be considered "non-covered" by my insurance carrier or Medicare, therefore I will become fully responsible for payment of these services.

WAIVER OF "USUAL, CUSTOMARY AND REASONABLE" CLAUSES

(For patients with "UCR" coverage) I acknowledge that the fees charged by Children's Health Center for services rendered to me, or to the person for whom I assume financial responsibility, may exceed the fees considered "usual, customary and reasonable", due to specialized services and staff. However, I agree to pay the Children's Health Center fees in full, even if the amount is greater than what I am reimbursed for from my insurance company.

BILL TO/PAYMENT INSTRUCTIONS

COMMERCIAL INSURANCE

I hereby authorize and request Children's Health Center t0 bill my insurance company for services provided to me.

MEDICAID

I request payment of Medicaid benefits to be made to Children's Health Center on my behalf for services rendered to me.

MEDIGAP

Name of Beneficiary

Medigap Policy Number

Health Insurance Claim Number

I request payment of Medigap benefits to be made to Children's Health Center on my behalf for services rendered to me.

PERMISSION FOR TREATMENT

Permission is hereby granted for physicians, employees or agents of Children's Health Center to render the patient named below such medical and surgical treatment as is deemed necessary.

PERMISSION TO RELEASE MEDICAL INFORMATION

I authorize Children's Health Center to release information from my medical record, or from the medical record of the person for whom I am legally responsible, to my/their insurance company, other third-party payors or their reviewing agencies. This information must be limited to that which is necessary to expedite claim processing. This authorization is valid for every visit to Children's Health Center or its affiliates until written notice revoking it is provided.

I release Children's Health Center of all responsibility for loss of confidentiality through access and/or copies made of records released in compliance to this authorization.

I have read all of the above and understand/agree to all provisions therein regarding responsibility for payment, release of information, and permission for treatment.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Name

Date

Patient or Legal Guardian's Signature

If Legal Guardian, Relationship to Patient

MEDICAL TREATMENT AUTHORIZATION FORM

Date

I hereby give my consent to Children's Health Center to administer treatment to my child

in the event of an emergency at which time I cannot be reached. I give consent to transport by ambulance, if the situation warrants.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Parent's Signature

Witnessed By

I hereby authorize the following person(s) to authorize medical treatment for my child named above, in my absence, including examination, performance of appropriate laboratory tests and x-rays, and the administration of any necessary medications, including immunizations.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Add additional Name

Authorization for Use/Disclosure of Protected Health Information

Patient's Name

Date of Birth

PERSON(S)/ORGANIZATION TO PROVIDE INFORMATION

Name

Address

City

State

Zip

INFORMATION TO BE RELEASED (Check ALL that apply)

History & Physical Exam

Date

Office Visits

Date

Lab Reports

Date

X-Ray Reports

Date

Patient Medical Photos

Date

Shot Records

Growth Charts

Other, Please specify

PERSON(S) ORGANIZATION TO RECEIVE INFORMATION:

I specifically authorize the release of information relating to:

Substance Abuse (including alcohol/drug use)

Mental Health (including psychotherapy notes)

HIV related information (including AIDS related testing

Generic Testing

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

PURPOSE OF DISCLOSURE

Changing Physicians

Consult/Second Opinion

Consulting Care

Legal

Other

If Other, Please Specify

The authorization will expire on

(NOTE: If left blank, it will expire 12 months from date signed).

I understand that I may:

Request a copy of this authorization.
Revoke this authorization at any time by notifying the providing organization in writing, and it will be effective on the date notified except to the extent action has already been taken in reliance upon it.
Refuse to sign this authorization and that my refusal will not affect to obtain treatment, payment, or my eligibility for benefits; however, the office has the right to deny the above request.
Inspect or obtain a copy of my information used or disclosed under this agreement and I am aware that I must request to do so with the completion of the appropriate form.

I understand that if the organization that receives the information is not health care provide, plan or business associates (of a provider or plan) covered by federal privacy regulations, the information described above may be re-disclosure by the recipient and no longer be protected by Federal privacy regulations. Additionally, the authorized provider would not be held responsible for any re-disclosures by the person or organization that receives the information.

Signature

Date

Parent/Legal Guardian/ Authorized Person

OFFICIAL USE ONLY:

INFORMATION RELEASED BY

DATE RELEASED

PHARMACY LISTING

Name

Date of Birth

Email address

Local Pharmacy

Address

City

State

Zip

Telephone

Fax

Medication List - Please list currently prescribed medications and any supplements.

Add Additional Medication

Allergies - Please describe any allergic reactions to medications, foods, or the environment.

DOMESTIC VIOLENCE SCREEN

1. Is anyone in the family afraid of or intimidated by other family members?

Yes No

If yes, Please describe

2. Anyone else in the family has been hurt by other family members?

Yes No

If yes, Please describe

3. Anyone else in the family has been threatened to hurt with or without weapon?

Yes No

If yes, Please describe

4. Is there anything going on in your home that makes you sad, scared or worried about your mom?

Yes No

If yes, Please describe

5. Is there anything going on in your home that makes you sad, scared, or worried about yourself?

Yes No

If yes, Please describe

Name

Date of Birth

Family Justice Center of Hillsborough County (813) 490-9428

The Spring of Tampa Bay (813) 490-5343 Ext 318

2-1-1 Tampa Bay (813)959•4914

CHILD ABUSE HOTLINE (800) 962-2873

Please bring to the exam room to review with the doctor.

Step 1: For the parent/Patient to fill out

Have you smoked a cigarette, even a puff, in the last 30 days?

Yes No

Would you like to receive FREE resources from the Tobacco Quitline?

Yes No Not sure

Would you like nicotine patch and gum to help you cut down or quit smoking?

Yes No Not sure

Step 2: For office use.(EMR Entry)

Document Tobacco Use/Exposure

Mother

Father

Patient

Other

Smoke-free Home Rule

Yes

Smoke-free Car Rule

Yes

No Car

Document Services provided

Prescription given for patch or gum

Enrolled in the Quitline

Enrolled in Smoke-free TXT

Set a date to quit for

Date

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Your information will be encrypted.