New Patient Packet

Main Contact:

Other Patient Information

Insurance Information

General Consent Form

Assignment of Benefits. I authorize CORNERSTONE CHILDREN’S CLINIC, LLC to submit claims on my behalf directly to Medicare/Medicaid/my private health insurance carrier. This means that CORNERSTONE CHILDREN’S CLINIC, LLC. will collect payment for supplies and services provided. I understand that I am financially responsible to the provider(s) for the charges not paid or payable. I authorize you to release any information necessary to insurance carriers regarding illnesses and treatment to process claims. This assignment will remain in effect until revoked by me in writing.

Consent for Treatment. I, as the patient or authorized representative of the patient, hereby grant consent for CORNERSTONE CHILDREN’S CLINIC, LLC. to provide all medical, preventative or behavioral treatments, tests and/or diagnostic tests to treat myself/the patient’s injury/illness on an outpatient basis. I acknowledge there is no guarantees have been made to me by the clinic or healthcare provider as to the results of healthcare services including diagnosing, examinations, or treatments in any clinic or hospital, or other healthcare organization.

Electronic Prescription. I understand CORNERSTONE CHILDREN’S CLINIC, LLC. utilizes electronic prescribing technology and participates with SureScripts. SureScripts operates the Pharmacy Health Information Exchange, which facilitates the electronic transmission of prescription information between providers and pharmacists. SureScripts also provides prescription data on any medications, known as medication history, which are prescribed to me/the patient.

Phone Calls. By providing contact information, I authorize CORNERSTONE CHILDREN’S CLINIC, LLC., its assignees, and third party collection agents to use the contact information I have provided to communicate with me and to place calls to my home/cellular/ employment telephone; leave voice or text messages; and use pre-recorded/artificial/voice messages and/or auto-dialing devices in connection with any communication to me.

Involvement of Others in Care. I authorize CORNERSTONE CHILDREN’S CLINIC, LLC. to discuss my/the patient’s care and medical needs with the following persons:

May We Contact You By Phone and Leave a Message About Your Care?

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.

Medication Management

The undersigned, as patient or authorized representative of a patient, understand and agree that Advanced Practice Registered Nurses (APRNs) do not treat chronic pain or obesity. I understand that as part of regular practice, my healthcare provider will review the Louisiana Prescription Monitoring Program to ensure that healthcare services are provided prudently. I also understand that some providers may choose to no write/prescribe controlled or scheduled medications and that I must abide by that decision while remaining a patient at this clinic. In addition, I understand and agree that should my healthcare provider choose, in his or her sole professional judgement within his or her scope of practice, licenses, and/or collaborative practice agreement, to prescribe controlled or scheduled medications that I will be subject to drug screens, with or without notice, to ensure that I am taking the medications as directed and that I am taking no other narcotic medication or illicit substance. I understand and agree that should my drug screen provide results that indicate I am not taking the medication as prescribed or in a manner that is contraindicated and my adversely affect my health, that the healthcare provider may not write any other scheduled medications to me in the future and that I could also be caused to be discharged from the clinic and healthcare provider's practice.

Healthcare Provider

The undersigned, as a patient or authorized representative of a patient, hereby understands, and agrees that healthcare services may be provided by an Advanced Practice Registered Nurse (APRN), Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), or a Physician. Also, I understand that the APRN has a collaborating physician who may or may not be at the clinic, and I am a patient of the APRN and this clinic, and not the patient of the collaborating physician. Further, I understand that the collaborating physician works, owns or operates another clinic and that he or she may or may not be available to provide healthcare services and may or may not accept my insurance or payments.

Notice of Privacy Practices

The undersigned, as a patient or authorized representative of a patient, hereby understands and agrees that as part of my healthcare, this organization utilizes health records describing my health history symptoms, examinations, test results, diagnoses, treatment, and any management for future treatment, in order for my healthcare provider to seek reimbursement as well as for various uses related to my healthcare provider's clinic administration. I consent to my provider using and disclosing my health information in connection with my treatment in order to get paid for healthcare related services provided to me and as necessary for clinic administration. I understand that medical Information and records may be released to other institutions, agencies, healthcare organizations of healthcare providers who accept me for medical or institutional care. In addition, I understand that my medical information may be released to my insurer(s), managed care organization(s), governmental entities responsible for paying for my care, and/or pharmaceutical manufacturers, agents, including, but not limited to payment, utilization review and quality assurance review, and to support applications for patient assistance.

Minor Patient Photograph (when applicable)

I consent for CORNERSTONE CHILDREN’S CLINIC, LLC. to photograph the minor patient for identification and or documentation purposes.

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.

Financial Policy

Please read prior to receiving services.

• PAYMENT: Payment is expected at the time of service. If your deductible has not been met, or a percentage is your responsibility, we expect payment when services are rendered. Even though insurance will be filed, you are responsible for any balance after insurance processes your claim.
• I understand and agree that the clinic will submit these charges to my healthcare insurer and if these charges are not covered by my insurance it is still my personal obligation to pay any and all charges.
• I assign all rights and causes of action, including but not limited to the title to any cause or action or rights of the patient with respect to collection of insurance benefits under Louisiana law.
• I further authorize any and all insurers that I might have of whatsoever nature, form of description, to pay my healthcare provider, and/or clinic, any and all amounts that may be due me by the said insurer. I further authorize any and all insurance companies that I have, to pay directly my treating provider, and/or clinic, and its agents or or third-party providers, any benefits due and payable under the terms of any and all insurance policies that I might have that would be effective for coverage and/or benefits to me.
• All charges for treatment become due and payable thirty(30) days after the date of service. This periods allow sufficient time to process insurance and make payment in full of any remaining balance. There will be a $25 charge for returned checks. If not paid within 30 days, CORNERSTONE CHILDREN’S CLINIC, LLC. will begin various collection activities including, but not limited by submitting the past due account to a collection agency.
• SELF PAYMENT (PRIVATE, CASH PAYMENT): If you have no insurance coverage we ask that you coordinate your care with our business office prior to your visit. We require an advance payment for professional services.
• MANAGED CARE: All managed care (HMO, PPO, etc.) co-payment amounts are due at the time of service. If your insurance plan requires a referral authorization from a primary care provider please present this at your initial visit. If you request an office visit without a referral authorization your insurance plan may deem this as “out of network” or “non covered” treatment, and you will be responsible for a larger amount or all of the charges. The patient acknowledges that it is the patient’s responsibility to be aware of what services are covered and agrees to pay for any service deemed to be non covered or not authorized by the plan.
• AUTOMOBILE ACCIDENT PATIENTS AND WORKERS COMPENSATION We DO NOT deliver healthcare services for the direct purpose to engage in litigation (e.g. accident or injury evaluation and/or management, workers compensation, for the purposes of litigation) I understand that this does not mean that he clinic and/or healthcare provider will not provide emergency stabilization or healthcare services immediately following an accident injury, or other trauma, but that the clinic and/or healthcare provider will not provide healthcare services post-accident, injury or other trauma for the sole purpose for intent to engage in litigation.
• Treatment of Minors. The undersigned, as a patient or authorized representative of a patient, understands and agrees that the parent or legal guardian must consent to the treatment of the child (for the purposes of this agreement a minor or child is defined as any person under the age of majority [17 or younger] in Louisiana) prior to the provision of healthcare services. The consent and authorization may be amended or revoked at any time by the parent or legal guardian.
• CHILDREN OF DIVORCED PARENTS: Responsibility for payment for treatment of minor children, whose parents are divorced, rests with the parent who seeks the treatment. Any court ordered responsibility judgment must be determined between the individuals involved, without the inclusion of CORNERSTONE CHILDREN’S CLINIC, LLC..
• Reproduction of Health Records. The undersigned, as a parent or authorized representative of a patient, understands and agrees that upon each visit the patient has an opportunity to receive a printed summary of their visit, a copy of any diagnostic tests or procedures, and any diagnostic tests or procedures, and any pertinent health education. I also understand that there is certain information about my health and healthcare services received available online thru the patient portal. I agree and understand that should I, or other party I designate in writing on a properly executed Consent to Release Protected Health Information form to receive my medical record., want a printed copy of my entire medical record that I will be required to pay the Louisiana mandated medical reproduction fees as prescribed in RS 40-1299.96 "If the original treatment records are generated, maintained, or stored in paper form, copies shall be provided upon payment of a reasonable copying charge, not to exceed one dollar ($1.00) per page for the first twenty-five (25) pages, fifty cents ($0.50) per page for twenty-six (26) to three hundred fifty (350) pages, and twenty-five cents ($0.25) thereafter, a handling charge not to exceed twenty-five dollars ($25.00) for hospitals, nursing homes, and other health care providers, and actual postage". "If treatment records are generated, maintained, or stored in digital format, copies may be requested to be provided in digital format charged at the rate provided by this item: however, the charges for providing digital copies shall not exceed one hundred dollars ($100.00), including all postage and handling charges actually incurred. If requested, the healthcare provider shall provide the requester, at no extra charge, a certificate page setting forth the extent of the completeness of records on file".
• SECONDARY INSURANCE: The Louisiana Department of Insurance requires the patient to provide secondary insurance coverage to the provider if applicable. Patient agrees to provide such information. Patient agrees to immediately notify provider of any future additions, changes or deletions in primary or secondary insurance coverage.
• If you have Medicaid coverage of any kind, you must notify us prior to your visit. This is part of your agreement with Medicaid, and failure to notify us of Medicaid coverage will result in full financial responsibility for services rendered.
• Before receiving services, you must verify that we are participating providers for your insurance company. It is also necessary that our primary care provider is listed as your primary care provider with your insurance company, if required by your contract with your insurance company.
• We will send a statement (to the billing address you provide) notifying you of any balances you may owe. If you have any questions or dispute the validity of this balance, it is your responsibility to contact our business office within 30 days after receipt of the initial statement. You can call (985) 500-3500.
• We may charge you a “No Show” fee if you fail to cancel or reschedule your appointment at least 24 hours prior to your appointment date.
• Failure to keep your account balance current may require us to cancel or reschedule your appointment.

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.

Pediatric New Patient Medical History Form

REASON FOR VISIT TODAY

PHARMACY(list pharmacy most frequently used for prescriptions)

FAMILY HISTORY – Is there a family history of:

MEDICAL HISTORY

Please select option next to the complaint(s) or ailment(s) that apply to the patient.

BIRTH HISTORY

ADOLESCENT HISTORY

OB/GYN HISTORY (females only)

TOBACCO HISTORY

ALCOHOL AND DRUG HISTORY

Has child ever used:

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.

Authorization to Release Medical Information to Cornerstone Children's Clinic, LLC.

to release the following information by mail, fax, electronically or orally to CORNERSTONE CHILDREN’S CLINIC, LLC.

Address: 44546 South Airport Rd., Ste F

Hammond, LA 70403

Phone: (985) 500-3500

Fax: (985) 500-3600

This authorization is given freely with the understanding that:

1. Any and all records, whether written, oral, or in electronic format, are confidential and cannot be disclosed without my prior written authorization, except as otherwise provided by law.
2. A photocopy or fax of this authorization is as valid as this original.
3. I may revoke this authorization at any time in writing, except where information has already been released.
4. CORNERSTONE CHILDREN’S CLINIC, LLC. Physician Services, its employees, officers, and physicians are hereby released from any legal responsibility or liability for receipt of the above information to the extent indicated and authorized herein.
5. Information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal and state privacy laws.
6. Treatment, payment, enrollment, or eligibility of benefits may not be conditioned on obtaining this authorization.

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.