Bama Pediatrics | 920 Rose Drive Northport, AL 35476
Thank you for choosing us as your primary care provider and/or allergy specialist. We are committed to providing you with quality and affordable health care. Please read it carefully, ask us any questions you have and sign in the space provided.
Our practice is committed to providing the best treatment to our patients. Thank you for understanding our payment policy.
I have read and understand the payment policy and agree to abide by its guidelines.
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.
Safeguarding the protect healthcare information (PHI) of our patients has always been and will always remain a primary concern of entire staff at BAMA PEDIATRICS LLC, Sudha Sagar Bennuri, MD and Bindu Bennuri, MD. Disclosure documentation and written consent to PHI as well as “chains of trust” with our vendors, appropriately executed contracts with business associates and “minimum necessary” release of information standards will provide a front line determent to any breach of practice procedures.
Moreover, through staff and provider training with periodic updates and monitoring Bama Pediatrics engineered office policy and procedure standards will protect orally (spoken) thereby ensure compliance with Federally mandated act known as Health Insurance Portability and Accountability Act of 1996 (HIPPA).
My affixed signature to this document acknowledges my awareness of the established practice and policy of Bama Pediatrics to protect the PHI of all patients under its care.
Please list all names below that are allowed to accompany your child(ren) to Bama Pediatrics.
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.
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