Demographics Packet Update

Please correct the errors described below.

PREFERRED COMMUNICATION

PARENTS/GUARDIANS

Additional Parents/Guardians

INSURANCE INFORMATION

Primary Insurance

Secondary Insurance

PHARMACY INFORMATION

PLEASE READ AND SIGN BELOW

MEDICAL CONSENT/ASSIGNMENT/RELEASE: I hereby agree to medical treatment rendered under control of West Valley Pediatrics, PC. I hereby assign my insurance benefits to be paid directly to West Valley Pediatrics, PC and I am financially responsible for any non-covered services. I also authorize West Valley Pediatrics, PC to release information as necessary to process all claims for services rendered. Rev 6/20

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.

West Valley Pediatrics Consent Form

The following individuals have my permission to bring my child to West Valley Pediatrics for medical care and treatment. I also authorize the same individuals to receive medical advice and information concerning my child, whether in office or over the phone. These individuals will also serve as emergency contacts for my child.

Additional Name

WEST VALLEY PEDIATRICS POLICES

Thank you for choosing West Valley Pediatrics (WVP) as your primary care physicians. This policy has been put in place to ensure that financial payments due are recovered to allow us to continue to provide quality medical care for our patients. It is important that we work together to assure that payment for services is as simple and straightforward as possible. Our practice manager and billing department will be glad to discuss these policies with you.

Please carefully read and initial by each statement and sign below

I have read and I understand the above policies of West Valley 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.

HIPAA Notice of Privacy Practices

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number. Upon request, a physical copy of our HIPAA policies is available for you to read while in the office

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices

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.

WVP Policy for Parents

The providers and staff of West Valley Pediatrics are here to take care of children. Our focus is on the medical, psychological and emotional health of your child(ren)- NOT legal issues involving divorce, separation, or custody agreements. That is why we ask that you read and agree to the following

  • Please make decisions regarding vaccinating your child(ren), circumcision, reproductive education, etc. prior to visiting our practice.
  • Either parent or legal guardian is able to schedule an appointment for their child, be present for the visit, and/ or obtain a copy of the visit summary. Unless there is a court order in the child’s record that restricts a parent’s rights. Please do not ask us to limit the other parent’s involvement in the child’s care
  • Payments are due and the time of service regardless of which parent is responsible for medical coverage. We are not a party to your divorce agreement. We will collect payment due from the parent who brings the child to the visit. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent
  • Both parents/ legal guardians can sign a “Consent to Treat” form. This means other persons (grandparents, nannies, etc.) are authorized to bring your child to our practice and can consent for treatment during that visit. We will NOT be involved in any disputes regarding named individuals on your child(ren)’s Consent to Treat form. Both parents/ legal guardians can see who is named on each other’s forms; however, we will not comply with requests to eliminate names on other’s form, unless instructed by the court. Please refer these requests to your attorney.
  • Additionally, we will not:
    • Call the other parent for consent prior to treatment or inform the other parent whenever visits are scheduled.
    • Restrict the involvement of either parent or legal guardian in your child(ren)’s care, unless authorized by law.
    • Tolerate appointment scheduling/cancelling patterns of behavior between parents.
  • It is the responsibility of both parents to communicate with each other about the patient’s care, office dates/visits and any other pertinent information relevant to the care of the child. Please do not ask our providers to call the non-attending parent following visits.
  • Should the issues that come between parents become disruptive to our practice or impede the care of children, we reserve the right to discharge your family from further 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.

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