Patient Registration Form

Responsible Party/Authorized Individuals for Treatment

It is a policy of Memorial City Pediatrics that individuals other than parents who are authorized above are able to schedule appointments and consent to medical treatment including lab, vaccines, antibiotic injections, and prescriptions

Primary Insurance

If yes please list insurance information:

Insurance assignment & release of information

• I authorize the release of my child’s medical information that is necessary to process insurance claims.
• I authorize the release of payment of medical benefits to my child’s provider.
• I have received notice of Memorial City Pediatrics privacy practice policy.
• I have read Memorial City Pediatrics office policy and agree to the terms listed.
• I understand that I am financially responsible for any deductibles & co-insurances fees and charges for non-covered services. Unless I am a member of an insurance organization Memorial City Pediatrics is contracted with, all charges are due at the time services are rendered.

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.

Telemedicine Consent

• I understand that telemedicine is the use of electronic information and communication technologies by a healthcare provider used to deliver services to an individual when he/she is located at a different location or site than I am.
• I understand that the laws that protect the privacy and the confidentiality of medical information including (HIPPA) also apply to telemedicine.
• I understand that I will be responsible for any copayments, coinsurances, deductibles, and charges for non-covered services that apply to my telemedicine visit.
• I understand that the purpose of telemedicine is to improve access to medical care by enabling a patient to review at their home. I understand that there are possible risks with the use of telemedicine, that’s including but not limited to; limited exams, Poor resolution imaging, Failure of the equipment, and rarely failure of security protocols causing a breach of privacy of personal medical information.
• I understand that by signing this form that I am consenting to receive health care services via telemedicine.

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.

Covid 19 Informed Consent

• Thank you for your confidence in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as "Coronavirus", at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection controls to limit transmission of all diseases in our office and continue to do so.
• Despite our careful attention to disinfection, use of personal barriers and practicing social distancing, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurants.
• Although exposure is unlikely, the risk cannot be eliminated completely.
• I am aware of this risk and consent to treatment under current circumstances.

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.

HIPPA Compliance Consent Form

HIPAA ( Health Insurance Portability Accountability Act) Compliance Patient Consent Form Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such revocation will not be retroactive

I understand that:

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
• The practice reserves the right to change the privacy policy as allowed by law.
• The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
• The patient has the right to revoke this consent in writing at any time and all full disclosure

Consent for Treatment

• I hereby voluntarily consent to care for my child encompassing diagnostic procedures and medical treatment by my physician, her assistants, or her designees as may be necessary for her judgment.
• I agree for my child to have HIV and another communicable disease testing in the event of a healthcare worker being exposed to my child’s bodily fluids

Immunization consent

I hereby voluntarily consent to vaccinate my child, as per the recommended schedules from the Center for Disease Control (CDC) and the American Academy of Pediatrics (AAP).

By signing this form, I have read and agree to the following consent forms; (HIPPA, CONSENT FOR TREATMENT AND IMMUNIZATION CONSENT)

MEDICAL HISTORY

Patient Medical History

Family History

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.