Facesheet for Adult Patients

ABC PEDIATRICS, LTD

Dr. Gus

Dr. Shanks

Dr. Law

Dr. Patel

Dr. Persak

Patient Information

Patient Last Name

First Name

Middle Name

Date of Birth

Patient(s) Address

Address

City

State

Zip Code

Mail statements to this address

Yes No

Cell Phone Number

Primary Email address

Parent/Guardian Contact Information

Pharmacy Information

Preferred Pharmacy

Phone Number

Address

Authorization for Use and Disclosure of Protected Health Information for Adult Patients

I understand and acknowledge that as of my 18th birthday, my parents and/or guardians will no longer be permitted access to my medical records, information, providers, or appointment status without my specific written permission. ABC Pediatrics, Ltd. will not speak with my parents, permit my parents to schedule appointments, or release medical information to my parents without my written consent in accordance with this document.

I DO NOT grant any access to my parents and/or guardians. NO medical information, records or appointment can be discussed or released.

For the purpose of helping me with my healthcare,

I WISH TO grant my parents and/or guardian access to my healthcare providers and/or medical information as follows:

I give the below-named individual(s) permission to act on my behalf. I understand that they may contact a physician or member of the staff at ABC Pediatrics, Ltd. to schedule appointments, discuss my healthcare, and access my medical records.

Authorization for Use and Disclosure of Protected Health Information for Adult Patients

Please specify if you wish to include the following:

Sexually transmitted disease/communicable diseases

Yes, include

No, do not include

Pregnancy/sexually activity

Yes, include

No, do not include

Mental Health

Yes, include

No, do not include

Substance abuse

Yes, include

No, do not include

Please list any other information to exclude:

This authorization will expire on:

Expiration date or defined event

My written revocation must be submitted to the Privacy Officer at ABC Pediatrics, Ltd.

Authorization and Acknowledgement

I understand copies of the Notice of Privacy Practices (HIPAA), Financial Policy, Cancellation/No Show Policy, and Electronic Communication Policy are posted in the office and on the website, www.abcpediatrics.net. I understand that I am bound by the terms of these policies and failure to do so could result in dismissal.
I authorize you to give me reasonable and proper medical care by today's standards.
I authorize the physician to release information related to any claim.
I recognize and accept full responsibility for all professional services rendered and further authorize the insurance company to pay benefits directly to the physician.
I understand that I must give at least one-hour notice when canceling a sick appointment and at least 24-hour notice when canceling a well visit, otherwise, I will be charged a $50 fee.
I understand that I am responsible for deductibles or uncovered expenses. This may include charges for screening forms, lab tests, and vision screenings that are required by law or recommended by the American Academy of Pediatrics.
I understand that an additional charge will be incurred for patients seen in the office during regularly scheduled evening, weekend, or holiday office hours.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

Signature

Date

Email address

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