Patient Information Form (New Born - 3 months)

Please correct the errors described below.

Guardian Information

Additional Guardians

EMERGENCY CONTACT

INSURANCE INFORMATION

Primary Insurance

Secondary Insurance

I understand and agree that my co-payment is due at the time of the visit and that regardless of my insurance status; I am ultimately responsible for the balance of my account for any professional services rendered. I will notify you of any changes in my child’s status to the above information. I consent to the care including diagnostic procedures, examinations, and treatment that the physician designates and considers to be necessary to treat my child’s condition. I certify that I have read all information on this sheet and have answered all questions to the best of my knowledge.

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.

Family Profile

Who lives in your home? (Include yourself and any significant others)

Additional Name

Family Health History

Please let us know who in the child’s family has any of the conditions listed below

Paternal Codes: Dad (DAD), Grandfather (PGF), Grandmother (PGM). Maternal Codes: Mom (MOM), Grandfather(MGF), Grandmother(MGM) Sibling Codes: Brother(BRO), Sister (SIS)

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 Health istory

List All Obstetric and Pediatric Primary Health Care Providers During This Pregnancy

Add new row

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 Allergies & Medication Summary

Allergies to Medication

Additional Medication

Allergies to Foods/Other

Additional Allergies

Current Medications, Vitamins & Supplements

Additional Medications

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.

Acknowledgment of Financial Agreement

Here at Glacier Pediatrics (GP), we consider every family’s situation individually and will do our best to offer as much help with the billing process as possible and provide affordable payment arrangements when needed. Please take a moment to read through and better understand the services we offer as well as your responsibilities.

  • Payment of Copay, Co-Ins., and Deductible is due at the time of service
  • Payment can be made by Credit/Debit Card, Check, or Cash or in-person, over the phone, or online from our website
  • Payment Plans are available

Regarding Insurance: GP is a Preferred Provider (PPO) for several Insurance Companies. This is subject to change, so we will announce any changes in a variety of methods (verbal, written). GP accepts and will bill all insurance plans as a courtesy to our patients. It is your responsibility to understand your policy. Your Insurance Policy is a contract between you and your insurance company. Your insurance policy is unique to you. GP cannot guarantee how your policy will cover a specific service - though we are happy to share general information.

Regarding Claim Processing: In order to maintain cost efficient billing processes for all of our patients, it is important that you provide GP with accurate and up to date information regarding your coverage at every visit. Inaccurate or delayed coverage information may result in an insurance denial. If a denial cannot be corrected, the balance for the non-covered services will be your responsibility. GP will ask to keep a current copy of your insurance card on file for your convenience and may ask for an updated copy even if no changes are reported.

Regarding Balances: Once GP has billed all insurances on file accordingly, if there is a balance remaining, it is the Guarantor’s responsibility to remit payment. GP will send a statement to the financially responsible individual on file (Guarantor). GP does not get involved with custody disputes – see our separated & divorced parent policy. Please communicate and coordinate payment cordially.

Glacier Pediatrics’ full Financial Policy is available by request or on our website under the forms tab labeled ‘Financial Policy’. Glacier Pediatrics’ full Separated & Divorced Parent Policy is available by request or on our website under the forms tab labeled “Separated & Divorced Parent Policy”

By signing this agreement, I have read, understand and agree to the policies described above. I understand these policies are subject to change at any time and that I may obtain a current Financial Policy agreement by contacting GP.

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.

Acknowledgment of Privacy Policy

This notice describes how medical information about you may be used and disclosed and how you can get access to this information

1. Your child’s healthcare record contains symptoms, examination and test results, diagnoses, treatment and a plan for future care or treatment. This information serves as a: basis for planning your child’s care and treatment, means for communicating with other health professionals who may contribute to your child’s care, legal document describing the care your child received, means by which you or a third-party payer can verify that services billed were actually provide, source of information for public health officials charged with improving the health of the nation, source of data only for our planning and marketing and a tool by which we may assess our processes and continually work to improve the care we render.

2. Although your child’s health record is the physical property of the healthcare facility that compiled it, the belongs to you and your child. You have the right to: request a restriction on certain uses and disclosures of the information as provided by 45 CFR 164.522, obtain a copy of the notice of the office privacy policy upon request, inspect and request a copy of the health record as provided for in 45 CFR 164.524, amend the health record as provided in 45 CFR 164.528, obtain an accounting of disclosures of your child’s health information as provided in 45 CFR 164.528, request communications of your child’s health information by alternative means (i.e. on paper, in person, our office location) and revoke your authorization to use or disclose health information except to the extent that action has already been taken.

3. Glacier Pediatrics, LLC is required to: Maintain the privacy of your child’s health information, Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about your child, Abide by the terms of this notice, Notify you if we are unable to agree to a requested restriction, Accommodate reasonable requests you may have to communicate health information by alternative means. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will make available a revised notice available at our office locations.

4. We will not use or disclose your child’s health information without your authorization, except as described in this notice: Glacier Pediatrics LLC is permitted to make uses and disclosures of protected health information for treatment, payment, and health care operations, as described in the following examples: For treatment - referral to specialists, For payment - release of chart note copies to an insurance company in order to facilitate reimbursement for procedures performed, For health care operations – processing of patient information by staff into the Electronic Health, Records and appointment scheduling by our staff. Glacier Pediatrics, LLC may be permitted or required, under specific circumstances, to use or disclose protected health information without the individual's written authorization such as in the case of a Public Health emergency. If a use or disclosure for any purpose described in the Privacy Regulation is prohibited or materially limited by other applicable State law, we are required to comply with the most stringent law. Other uses and disclosures will be made only with the Individual's written authorization, and the individual may revoke such authorization.

5. Glacier Pediatrics, LLC may contact the parent or guardian to provide appointment reminders or information about treatment alternatives and other health-related benefits and services that may be of interest to the individual or patient. Authorization forms are available if you wish for this information to be released to anyone other than the parent, guardian or patient.

Glacier Pediatrics’ full Privacy Policy is available by request or on our website under the forms tab labeled “Privacy Policy”.

By signing this agreement, I have read, understand and agree to the policies described above. I understand these policies are subject to change at any time and that I may obtain a current Privacy Policy agreement by contacting Glacier Pediatrics.

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.

Medicaid Eligibility Questionnaire

Effective October 17, 2011 Glacier Pediatrics is required by Alaska Medicaid to provide this questionnaire on ethnicity and race to its patients, regardless of their status with Alaska Medicaid. Please note that while we are required to provide you with this questionnaire you are not required to answer any of the following questions. If you choose to decline, please check the box at the bottom of this form.

CHECK HERE IF YOU WISH TO DECLINE:

Patient Eligibility Screening Record Vaccine for Children (VFC) Program

VFC eligibility screening must be conducted whenever a child age 18 year and younger receives state-supplied vaccines. Although screening must take place during EACH immunization visit to ensure the child’s eligibility status has not changed, documentation on this form is required only during the initial visit of a VFC-eligible child and during any subsequent visit in which it is determined the child’s eligibility status has changed. The screening record may be completed by the parent/ guardian/ individual of record or by the health care provider. Verification of responses is not required. This form (or similar information) must be maintained in the child’s medical record.

Parent/Guardian of Record

Below For Nurse Use Only

Eligibility Changes

Although VFC eligibility status must be reviewed EVERY time a vaccine is administered, documentation is required on the table below ONLY when changes in VFC eligibility occur

VFC Eligibility Status (Place an ‘x’ under the appropriate category)

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