New Patient Paperwork

Wonder Kids Specialty Pediatrics

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Patient Information

Guarantor

(Parent/ Legal Guardian/ Person Completing Form)

Emergency Contact

Primary Insurance

Subscriber/ policy holder (if other than patient)

Secondary Insurance

Subscriber/ policy holder (if other than patient)

To the best of my knowledge, the above information is complete and accurate.

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

Medications, Allergies, & Health History

Birth History

Cholesterol/ Heart Disease Screening: (age 2 years and up)

Tuberculosis Screening:

Lead Screening: (age 5 years and up)

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

Family and Social History

Family Medical History: Does anyone in your family suffer from any of the following? Please choose Yes / No If yes, please list who.

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List all individuals living with this patient:

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

Acknowledgement and Authorization

  • Privacy Practices: I have read and understand the HIPAA/ Privacy Policy for Wonder Kids Specialty Pediatrics.
  • Assignment of Benefits: I hereby assign my insurance benefits to be paid directly to the healthcare provider.
  • Disclosure of Information: I authorize Wonder Kids Specialty Pediatrics to release medical information required to process my claim and send prescriptions electronically to my pharmacy.
  • I have read and understood the Office policies and Financial Responsibility for Wonder Kids Specialty Pediatrics.
  • I authorize Wonder Kids Specialty Pediatrics to obtain/ have access to my medication history.
  • I understand that Wonder Kids Specialty Pediatrics will assist with insurance verification and precertification requirements which are the responsibility of the policyholder but will not assume responsibility for pre-certification or any impact it may have on the insurance payment.
  • As consideration for the services provided, payment is guaranteed for any amount due from me for services provided by Wonder Kids Specialty Pediatrics.
  • Consent to Treat: Wonder Kids Specialty Pediatrics and its Medical Staff are hereby authorized to administer any medical, diagnostic, or therapeutic treatment as may be deemed necessary or advisable. I have the right to consent or refuse consent, to any proposed procedure or therapeutic course, absent emergency or extraordinary circumstances.
  • I authorize my provider’s office to contact me by: (Choose below)

HIPAA Privacy and Release of Information Authorization

I hereby authorize Wonder Kids Specialty Pediatrics and it affiliates, its employees and agents, to use and disclose protected health information (e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided to me which identifies my name, address, social security number, Member ID number) for the purpose of helping me to resolve claims and health benefit coverage issues.

I understand that any personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person/ organization and may no longer be protected by applicable federal and state privacy laws.

I understand that I have the right to revoke this authorization by providing written notice. However, this authorization may not be revoked if, its employees or agents have taken action on this authorization prior to receiving my written notice. I also understand that I have the right to have a copy of this authorization.

I understand that the information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal and state law.

I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my eligibility for benefits or enrollment or payment for or coverage of services.

I have been advised of this practice’s Privacy Practices, Assignment of Benefits, and Disclosure of Information policies. I grant the practice Medication History Authority.

By signing this form, I represent that I am the legal representative of the Member Identified above and will provide written proof (e.g., Power of Attorney, guardianship papers, ID, etc) that I am legally authorized to act on the Member’s behalf with respect to this authorization form.

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

Office Policies for Patient

Office Hours: Our office is open during the following hours. We will be closed daily for lunch from 1 pm-2 pm. Monday 9:00 am - 6:00 pm, Tuesday-Thursday 9:00 am - 5:00 pm, Friday 9:00 am - 1:00 pm We will be closed on weekends, major holidays, and most local school closure dates. (Days that Lawton Public Schools and Cache Public Schools are closed or not in session)

Emergencies: Please call 911 or go to the nearest emergency room if you feel your child has a life-threatening emergency.

Appointments: We take scheduled appointments and try to accommodate same-day sick visits for our patients. If you need a same-day appointment, please contact us as soon as possible. We encourage our patients to schedule routine care well in advance. In order to provide service to all families that have scheduled appointment times, patients who arrive more than 15 minutes late for their scheduled appointments may be asked to reschedule.

Insurance and Financial responsibility: You are responsible for paying all co-pays at the time of service. We accept cash, credit cards, and checks. All co-pays, co-insurance, deductibles, and non-covered services are the responsibility of the patient or the patient’s legal guardian. We are contracted and in-network with most major insurance companies, however, it is your responsibility to know your specific insurance plan details and that they will allow you to see the providers in our clinic. As a courtesy to our patients, we file insurance claims to your insurance carrier. In order to do this, we require all information to be completed on the Patient Registration Form. We must have this information prior to the appointment. Please present your insurance card and a picture ID for the patient’s legal guardian as well. We make every effort to verify your insurance and benefits. If our office is unable to verify current coverage, you will be required to pay for your visit at the time of the appointment. If you do not have insurance coverage your will be required to pay the full cost of the visit at the time of the appointment. Failure to pay outstanding balances within 60 days may result in the account being turned to collections. Please provide any updated insurance information prior to them being seen.

Prescriptions: Please inform Wonder Kids Specialty Pediatrics of the pharmacy you wish to use and update us if this should change. You must be a current patient for any prescriptions or refills to be sent. We ask for 3-5 business days advance notice to process prescription refills. Your prescription will be e-scribed to the pharmacy of your choice.

Cancellations and No Show: We understand that circumstances may prevent you from keeping scheduled appointments but ask that you notify us as soon as possible. Please notify us at least 24 hours in advance to cancel or reschedule appointments. Failure to notify the office in advance will result in a no-show being marked on your chart. After two no-show appointments, you may be asked to find another provider.

Medical Records: Per HIPPA Guidelines, copies of medical records must be requested in writing. To ensure your privacy, a form for the release of medical information must be completed prior to receipt of these materials. There may be a fee for copying records in the office. Records may be faxed to another medical provider at no charge.

Patient expectations: As a patient, you should expect that the provider and staff treat you professionally and respectfully. It is also expected that you and your family members treat our providers and staff respectfully. Wonder Kids Pediatrics does not tolerate rude, offensive, or threatening behavior. Any such behavior will result in termination from the clinic and you will be asked to find another provider.

Office Policies for our Patients Receipt Acknowledgement Form

By signing below, I acknowledge that I have received, reviewed, understand, and will comply with the policies explained in the Office Policies for Patients Wonder Kids Specialty Pediatrics form.

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

Permission to Authorize Medical Care of a Minor

I, the undersigned parent or legal guardian does hereby give the following individual(s)

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Permission to authorize Wonder Kids Specialty Pediatrics to provide routine or emergency medical care as they deem necessary on my behalf for my minor child, and in doing so to obtain confidential information under HIPAA laws regarding my child’s medical records, treatment, and diagnosis.

I (Choose below) authorize my minor child age 16 and over to come to appointments by his/herself for medical care.

This authorization shall remain in effect until it is revoked by me.

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

My Child Sees the following Specialty Providers:

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

Medical Home Agreement

The Medical Home Agreement concept is an AGREEMENT between YOU and YOUR PROVIDER, to focus on meeting ALL of your Healthcare needs.

As your Medical Home Primary Care Provider (PCP), we agree to:

  1. Honor your rights as a patient, and treat you with dignity and respect.
  2. We will focus on listening to your concerns, educating you on your health care needs and preventive services.

  3. Focus on treating you as a whole person: physically, mentally, and emotionally.

  4. Focus on providing you with ongoing, quality, and safe medical care, including prevention of future health complications.

  5. Work to schedule timely office appointments for your chronic and urgent healthcare needs.

  6. Be available to you 24 hours a day, by office appointment, phone calls, and/or other electronic communication.

  7. Provide you with other healthcare resources when we are absent or unavailable.

  8. Provide you with referrals to specialists as deemed medically necessary by your PCP.

  9. Provide you with treatment, medications, equipment, and any other resources deemed medically necessary by your PCP.


As a Medical Home Patient, your responsibility is the following:

  1. Work with us, as your PCP, to meet all of your health care needs.
  2. Communicate with us about all your healthcare concerns and goals.
  3. Report any changes related to your health, treatments, medications, etc.
    • This includes the use of all medications - prescription, over-the-counter, herbal and street drugs.
    • This also includes any medical equipment being used or that has been ordered or recommended for use
  4. Call us before going to the Emergency Room, unless it is life-threatening.
  5. Notify us after any Emergency Room, Urgent Care Clinic or Hospital visit.
  6. Schedule medical appointments in a timely manner, including follow-up appointments.
  7. Keep appointments as scheduled with us and any appointments scheduled with a specialist.
  8. If you cannot keep an appointment call before your appointment time to cancel or reschedule the appointment.
  9. You may be dismissed from your PCP if you repeatedly miss appointments without notice or do not follow the responsibilities listed in the medical home agreement.

Your Healthcare is a TEAM Approach involving BOTH YOU and YOUR PROVIDER.

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

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