Pediatric: 13-17 yrs

PARENT/GUARDIAN CONTACT INFORMATION

The person accompanying the minor shall be the responsible party for payment on the account.

INSURANCE POLICY HOLDER

INSURANCE INFORMATION

The patient's insurance card must be presented at the time of your appointment for each visit. Insurance won't be billed until a copy of the card is received. COPAYS are due atthe appointment. Failure to pay the copay will resultin a $10 fee. Self-Pay patients and outof-network patients are required to pay for the visit in full at the time of service. The patient authorizes Family Practice Ass ociates to release information to the insurance company in order for current and future claims to be processed. Patients 18 years and older will be responsible for the account unless we received signed notification from your responsible party.

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.

Please read and sign our HIPAA, financial policy, and privacy practices on the reverse side of the form.

HIPAA Privacy Authorization Form

Authorization for Use or Disclosure of Protected Health Information

AUTHORIZATION: I authorize Family Practice Associates to use and/or disclose certain Protected Health Information (PHI) about me to the following individuals. (Please print full name.)

Your initials are required to withhold the following information:

I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations. The medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I direct. I understand that treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization. I may revoke this authorization at any time by notifying FAMILY PRACTICE ASSOCIATES, in writing, of my desire to revoke it. The notice will not apply to actions taken by the requesting person/entity prior to the date FAMILY PRACTICE ASSOCIATES receives the request.

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.

REQUIRES PATIENT SIGNATURE:

I acknowledge that I have received a copy of the NOTICE OF PRIVACY PRACTICES regarding my health 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.

I acknowledge that I have received a copy of the NOTICE OF PRIVACY PRACTICES regarding my health information.

I acknowledge that I have received a copy of the NOTICE OF OFFICE AND FINANCIAL POLICIES.

As part of our electronic health record standard, would you be willing to state your race and ethnicity? This is an important part of your medical history. Some medical conditions are more prevalent in certain races, such as diabetes, hypertension and cancer.

Informed Consent for Telemedicine Services

• I understand that telemedicine is the use of electronic information and communication technologies by a healthcare provider to deliver sevices to an individual when he/she is located at a different location or site than I am, and I must be physically located in the state of Colorado when receiving this service through Family Practice Associates
• I understand the potential limitations of telemedicine, and that services will be provided to the best ability of the healthcare provider.
• I understand that Family Practice Associates utilizes the Hippo Health software program to conduct telemedicine services, and I agree to installing this application (app) on my cell phone, computer and/or tablet in order to receive telemedicine.
• I understand that the telemedicine visit will be performed through a two-way video link-up. The healthcare provider will be able to see my image on my cell phone screen, computer monitor or tablet, and the provider will hear my voice. I will be able to hear and see the healthcare provider.
• I understand that technical difficulties may occur before or during the telemedicine session, and that the healthcare provider may conduct the appointment via regular telephone communication if such difficulties interfere with utilizing Hippo Health.
• I understand the the laws that protect privacy and the confidentiality of medical information, including HIPAA, also apply to telemedicine.
• I understand that I will be responsible for any copayments or other financial patient responsibility, and that I am responsible for knowing whether my insurance plan covers telemedicine.
• I understand that by signing this form that I am consenting to receive health care services via telemedicine.

NEW PATIENT INTAKE FORM – Pediatric (13-17 years of age)

CURRENT HEALTH CONCERNS:

List in order of importance the health concerns that you would like to address today?

ALLERGIES:

Are you allergic to any medications, herbs, foods, animals or any other substances not mentioned?

CURRENT MEDICATIONS:

Vitamins, minerals and herbal supplements you are taking:

FAMILY HISTORY:

IMMUNIZATIONS:

PAST MEDICAL HISTORY:

MEDICAL CONDITIONS:

Select (C) if currently experiencing condition or (P) if you have previously experienced condition.

LIFESTYLE / ENVIRONMENTAL FACTORS:

REVIEW OF SYSTEMS:

Please check off any conditions you currently have.