New Patient Registration Forms

Date

Primary Language Spoken

LIST ALL CHILDREN IN THE FAMILY

Add Child

Home Street Address

City

State

ZIP Code

Children live with

Parent/Guardian #1 Parent/Guardian #2 Both

PARENT/LEGAL GUARDIAN RESPONSIBLE FOR PATIENT'S FINANCIAL OBLIGATIONS

PARENT/LEGAL GUARDIAN #1 (OR PATIENT IF 18 YEARS OR OLDER)

First Name

Middle Name

Last Name

Relationship to Patient

Social Security #

Date of Birth

Home Phone

Cell Phone

Email address

Street Address (if different from above)

City

State

Zip

Employer Name

(If not working, please indicate N/A.)

Occupation

Address

City

State

Zip Code

Work Phone (including extension)

PARENT/LEGAL GUARDIAN #2

First Name

Middle Name

Last Name

Relationship to Patient

Social Security #

Date of Birth

Home Phone

Cell Phone

Email address

Street Address (if different from above)

City

State

Zip

Employer Name

Occupation

Address

City

State

Zip Code

Work Phone (including extension)

NEAREST RELATIVE OR EMERGENCY CONTACT INFORMATION

First Name

Last Name

Relationship to Patient

Home Phone

Cell Phone

Referred By

PHARMACY INFORMATION

Pharmacy Name

Phone Number

Address

City

State

Zip Code

HEALTH INSURANCE INFORMATION

Insurance Company

Insurance Company Phone #

Subscriber's Name

Subscriber's Employer

Subscriber's Date of Birth

Subscriber's Social Security #

ID/Policy #

Group #

Effective Date

ASSIGNMENT OF BENEFITS AND AUTHORIZATIONS

I hereby authorize and direct my insurance company to make payments directly to the providers of WEST BROWARD PEDIATRICS, benefits allowable otherwise payable to me and/or my dependents. I understand that I am responsible for charges not paid under this Assignment. This Authorization will remain in effect until rescinded by myself in writing. I further permit a copy of this Authorization be used in place of the original. This Authorization is to apply to all claims submitted by the providers of WEST BROWARD PEDIATRICS. I hereby authorize the providers to release any information required in the course of the examination or treatment.

To avoid misunderstandings regarding medical insurance, all patients should understand that all professional services rendered are charged directly to the patient and that all patients are personally responsible for payment of fees. As a courtesy, we will prepare all necessary forms to help you obtain benefits from insurance companies. We do not render our services on the basis that insurance companies will pay our fees. If your insurance company does not cover the fees in full, the balance is due in full and payable by you.

A $10.00 Administrative Fee, due to processing services will be applied to all unpaid balances not paid by the due date on your monthly statement.

I authorize WEST BROWARD PEDIATRICS and it's agents Dr. Michael Morrison, Dr. Alicia Salland, Dr. Paole Pare, Brenda Austin, APRN, Amber Badal, APRN, and Kelly Stars, APRN to render any emergency care for my children if I cannot be located at the time of emergency.

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.

Parent/Legal Guardian Signature (Or Signature of Patient 18 Years or Older)

Date

HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing healthcare services to you, to pay your healthcare bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment

We will use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment

Your protected health information will be used, as needed, to obtain payment for your healthcare services. For example, obtaining approval for a hospital procedure or stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations

We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements; Legal Proceedings: Law Enforcement, Coroners, Funeral Directors and Organ Donors; Research: Criminal Activity, Military Activity and National Security, Workers' Compensation, Inmates. Under the law, we must 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 requirement of Section 164.500.

Other Permitted and Required Uses and Disclosures

These disclosure will be made only with your consent, authorization or opportunity to object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights

Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and receive a copy your protected health information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restrictions to apply.

Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to receive this notice alternatively i.e. electronically.

You have the right to have your physician amend your protected health information. If we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

We reserve the right to change terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before April 14, 2003.

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 (954) 423-2300.

Your signature below is only acknowledgement that you have received this Notice of our Privacy Practices for you and your child/children:

Add Child

Signature of Parent/Legal Guardian

Date

Patient and Family History

Today's Date

Patient's Name

Date of Birth

Does the patient have a history of:

Serious past injury or accidents

Yes No N/A

Comments

Surgeries

Yes No N/A

Comments

Hospitalizations

Yes No N/A

Comments

Chickenpox

Yes No N/A

Comments

Frequent ear infections

Yes No N/A

Comments

Problem with ears or hearing

Yes No N/A

Comments

Asthma, bronchitis, bronchiolitis, pneumonia

Yes No N/A

Comments

Heart problems or heart murmur

Yes No N/A

Comments

Anemia or bleeding problem

Yes No N/A

Comments

Blood transfusion

Yes No N/A

Comments

Frequent abdominal pain

Yes No N/A

Comments

Constipation requiring a doctor visit

Yes No N/A

Comments

Bladder or kidney infection

Yes No N/A

Comments

Bed-wetting (after 5 years of age)

Yes No N/A

Comments

If females, have menstrual periods started?

Yes No N/A

Comments

If female, any problems with periods?

Yes No N/A

Comments

Chronic or recurrent skin problems (Acne, Eczema)

Yes No N/A

Comments

Frequent headaches

Yes No N/A

Comments

Convulsions or other neurological problems

Yes No N/A

Comments

Diabetes

Yes No N/A

Comments

Thyroid or other endocrine problems

Yes No N/A

Comments

Use of alcohol or drugs

Yes No N/A

Comments

Patient's Allergy History

Does the patient have an allergy to:

Patient has no known allergies (NKDA)

Yes No N/A

Comments

Penicillin (Amoxicillin, Augmentin)

Yes No N/A

Comments

Cephalosporins (Ceclor, Keflex, Cefzil)

Yes No N/A

Comments

Sulfa (Septra, Bactrim)

Yes No N/A

Comments

Macrolides (Zithromax, Biaxin, Erythromycin)

Yes No N/A

Comments

Any other antibiotics

Yes No N/A

Comments

Peanuts

Yes No N/A

Comments

Milk

Yes No N/A

Comments

Eggs

Yes No N/A

Comments

Seafood

Yes No N/A

Comments

Other Foods

Yes No N/A

Comments

Bess/Wasps

Yes No N/A

Comments

Indoor Allergies

Yes No N/A

Comments

Outdoor Allergies

Yes No N/A

Comments

Animal

Yes No N/A

Comments

Latex

Yes No N/A

Comments

Other

Yes No N/A

Comments

Parent's/Family's Social History

Are parents married

Yes No N/A

Comments

Divorced (under comments, put whom the patients live with, Mom or Dad)

Yes No N/A

Comments

Does non-custodial parent have visitation

Yes No N/A

Comments

Does the patient have any brothers or sisters

Yes No N/A

Comments

Does the family have any pets

Yes No N/A

Comments

Are there any smokers in the home

Yes No N/A

Comments

Family's Medical History

History of mom, dad, and patient's grandparents

Deafness

Yes No N/A

Comments

Nasal Allergies

Yes No N/A

Comments

Asthma

Yes No N/A

Comments

Tuberculosis

Yes No N/A

Comments

Heart Disease (prior to age 50)

Yes No N/A

Comments

High Blood Pressure (prior to age 50)

Yes No N/A

Comments

High Cholesterol

Yes No N/A

Comments

Anemia

Yes No N/A

Comments

Bleeding Disorder

Yes No N/A

Comments

Liver Disease

Yes No N/A

Comments

Kidney Disease

Yes No N/A

Comments

Diabetes (prior to age 50)

Yes No N/A

Comments

Bed-wetting (after 10 years of age)

Yes No N/A

Comments

Epilepsy or Convulsions

Yes No N/A

Comments

Alcohol Abuse

Yes No N/A

Comments

Mental Illness

Yes No N/A

Comments

Mental Retardation

Yes No N/A

Comments

Immune Problems, HIV, AIDS

Yes No N/A

Comments

Additional Pertinent Conditions

Yes No N/A

Comments

Signature of Parent/Legal Guardian

Relationship to Patient

Record Release Authorization

Attention: Medical Records Department

Previous Physician

Address

City

State

Zip Code

Phone

Fax

Please forward records to West Broward Pediatrics

By Email: RECORDS@WESTBROWARDPEDIATRICS.COM

By FAX: 954-424-4200

I authorize and request you to release the following records to West Broward Pediatrics

Problem List
Growth Chart
Last 2 Well Check Visits
Full Immunization Record

Authorization to Release Protective Health Information

I DO authorize release of information related to AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus) infection, psychiatric care and/or psychological assessment, and treatment for alcohol and/or drug abuse. I DO NOT authorize release of information related to AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus) infection, psychiatric care and/or psychological assessment, and treatment for alcohol and/or drug abuse.

*FOR CHILDREN 6 MONTHS AND YOUNGER, PLEASE PROVIDE ALL RECORDS.

Add Child

Parent's or Legal Guardian's Name

Phone

Address

City

State

Zip Code

Parent/Guardian Signature

Date

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