New Patient Registration Packet

PARENT / GUARDIAN

Emergency contact (other than parent)

Pharmacy Information

Insurance Information

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.

Notice of Privacy Practices

A Plus Pediatrics is required by law to protect the privacy of your child protected health Information (PHI). Please read this document carefully and sign the bottom of the form to acknowledge that you have received it. Uses and Disclosures of Protected Health Information: Your child’s PHI may be used and disclosed by our physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to your child, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law. Treatment: Your child’s PHI may be shared with employees and contractors of the provider, or with other health care providers who are treating you or consulting in your child care. Payment: Your PHI may be shared with your insurer or other third-party payer who is responsible for paying all or part of the cost for your child care. Health Operations: A Plus Pediatrics may use and disclose information that is necessary for our operation, such as internal quality assessments, contacting other health care providers about treatment alternatives, licensing, employee review activities, etc. We may use sign in sheet at the registration desk and we may call you by name in the waiting room when the physician is ready to see you. We may use or disclose your child’s PHI In the following situations without your authorization, including: public health issues as required by law, communicable disease, health oversight, abuse or neglect, FDA requirement, legal proceedings, law enforcement, coroners, funeral directors, organ donations, research, criminal activity, military activity, national security, and worker's compensation. We are required by law to make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

You may be asked to sign a specific authorization for release of medical records, which will authorize us to make specific disclosures that are not covered under the above sections. You may revoke any consent or authorization provided to us by giving a written notice of evocation. Your rights:

1. You have the right to Inspect and copy your health information.
2. If you feel that the health information we have about your child is incomplete or inaccurate, you have the right to request an amendment to your child’s medical records. The request must be made in writing with the reason for the request if we do not agree with your request, you have the right to ask that your statement be placed in the medical record.
3. You have the right to find out how your child’s health Information Is used and to whom it is disclosed. You may request an accounting of your medical record disclosures made by us, except for the disclosures made for treatment, payment, and health care operations.
4. You have the right to request a restriction of your child’s PHI. This means you may ask us not to use or disclose any part of your child’s PHI for the purposes of treatment, payment or healthcare operations. You may also request that any part of your child’s PHI not be disclosed to a specific person, or for notification purpose as described in this Notice of Privacy Practices. Your request must be in writing and must states the specific restriction requested and to who you want the restriction to apply. Your physician is not obligated to agree to a restriction that you may request if the physician believes it is in your best interest to permit use and disclosure of your child’s PHI. You then have the right to use another Healthcare Professional.
5. You have the right to receive a paper copy of this notice. We reserve the right to change the terms of this notice and will inform you by mail of any changes. Complaints: You may complain to us or to the Secretary of Health and Human Services If you believe we have violated your privacy rights. You may file a complaint with us by notifying our HIPAA Compliance Officer in person, by phone or in writing at the office address. We will not retaliate against you for filing a complaint. Please acknowledge that you have reviewed this notice of Privacy Practices by signing below.

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.

Insurance authorization and payment policy

Service payment: Your healthcare is very important for us. We are pleased to discuss with you any questions you may having concerning a bill. Copayments in full are due at the time of service. Your insurance policy is a contract between you and your insurance company. If you have any question(s) regarding coverage of services, please contact your insurance company for clarification. There is a $25 charge for all returned checks. There is a $25 charge for all missed appointments cancelled less than 24 hours in advance. If you need to cancel an appointment, you must call the office at least 24 hours in advance.

If you are more than 15 minutes late for your scheduled appointment we cannot guarantee you will be seen at that time and you will be charged $25 for the missed appointment. Copies of medical record will result in a $20 charge.

Insurance information: Always bring your health insurance card information and notify us for any changes in insurance, home address, phone number or email.

Payment authorization: I hereby authorize A Plus Pediatrics to apply for benefits on minor’s behalf for covered services rendered. I request payment to be made directly to A Plus Pediatrics, LLC. I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information for this or, any related claim to the above named billing agent. I permit copy of this authorization to be used in place of the original. Either the above-named carrier or I may revoke this authorization at any time in writing. I agree to be legally responsible for any and all charges incurred for the patient name above.

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.