Lactation Information Sheet

Today's Date

Mother's Birthdate

First Name

Middle Initial

Last Name

Address

City

State

Zip Code

Primary Phone:

Cell Phone:

Other Phone:

Emergency Contact:

First Name

Last Name

Primary Phone:

Do we have permission to contact this person regarding matters of your care?

Yes No

Preferred Method of Notifications

Phone Call Text Message Email

When an email address is provided, you will be web enabled for our patient portal:

Email address

Ethnicity

Hispanic Non-Hispanic Prefer not to report

Race (Check all that apply)

White

African American/Black

Asian

Asian Indian

Native American

Native Hawaiian

Other Pacific Islander

Other Race

Prefer not to report

Preferred Language

English Spanish Other

If other, please specify:

Interpreter needed?

Yes No

Insured Subscriber / Responsible Party Information

Name of Primary Insurance Company

ID #

Group #

Name of Subscriber

Subscriber's address, if different from patient

Subscriber's Phone Number

Subscriber's Employer

Subscriber's Date of Birth

Subscriber's Relationship to Patient

Insurance Same as Child Patient?

Yes No

If Mother's insurance is the same as child's insurance on file, please list child's name and birthdate below:

Child Patient's Name

Child Patient's Date of Birth

Responsibility for Payment for Services Rendered

By signing below, I authorize Bloomington Pediatrics, LTD to submit claims for services rendered to the insurance company/companies listed by me. I authorize the release of protected health information to said insurance companies for the processing of claims. I understand that I am responsible for payment of services rendered and agree to pay any fees for services not covered by insurance, including, but not limited to coinsurance and deductible amounts. I agree to pay at the time of service any co-payment required by my insurance. I also understand I will be held responsible for the payment of any collection fees should my account be sent into collection proceedings.

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.

Signature

Date

Consent to Medical Treatment

By signing below, I consent to and authorize the physicians, nurses and other healthcare providers at Bloomington Pediatrics, LTD to perform appropriate healthcare examinations, treatment, diagnostic testing or medication administration as deemed medically necessary by their professional judgment. I know that there are some risks with all medical treatments and procedures and I understand that no one can guarantee how well treatments or procedures will work.

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.

Signature

Date

Authorization to Release Information

By signing below, I hereby authorize Bloomington Pediatrics to contact me in my preferred method indicated below to send me appointment reminders and other practice information. I also authorize Bloomington Pediatrics to release any information required during my child’s care and treatment, including referrals to other medical facilities for specialist care, in response to requests from my insurance company for quality assurance measures, and other appropriate disclosures of protected health information as outlined in Bloomington Pediatrics’ Notice of Privacy Practices document. I further acknowledge I have been offered a copy of the Privacy Notice which describes in detail how my child’s health information is used and shared in accordance with the US Department of Health & Human Services requirements under the Health Insurance Portability & Accountability Act (HIPAA). I understand I may obtain a current copy at the front desk or by visiting the practice website at www.bloomingtonpediatrics.com.

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.

Signature

Date

Your information will be encrypted.