Patient Information Sheet

Today’s Date:

Name of Patient's Pediatrician / Provider:

Patient Information

Patient's Legal Name (first, middle, last):

Patient’s Birthdate:

Patient's Preferred Name / Nickname:

Gender Assigned at Birth:

Male Female

Gender Identity:

Male Female Non-Binary Transgender Prefer not to report

Preferred Pronouns:

He/Him She/Her They/Them

Sexual Orientation:

Hetrosexual Bisexual Homosexual Prefer not to report

Gender Identity / Sexual Orientation Privacy Status:

Private Public

Primary race : (choose all that apply)

African American/Black

Asian

Other

Asian Indian

Caucasian/White

Prefer not to report

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

If Other, Please Specify:

Ethnicity:

Non-Hispanic Hispanic Prefer not to report

Preferred language:

English Spanish Other

If other, please specify:

Interpreter Needed?

Yes No

Parent / Legal Guardian Information

Primary Parent Name:

Relationship to Patient:

Mother Father Stepmother Stepfather Other

Primary Home Address:

Primary Phone:

Primary Email Address:

Enable Patient Portal Access for this Email?

Yes No

Add additional parent / legal guardian

Does the patient live with BOTH biological parents?

Yes No

If NO, what is the patient's current living situation?

Single Parent Custody Joint Custody Foster Care Adoptive Family Other Legal Guardian(s):

Please provide all court documents for legal guardianship, custody agreements, parental limits for medical decision making, or any other legal proceedings affecting the patient.

If other, please specify:

Sibling Information

Sibling's Legal Name:

Sibling's Birthdate

Add Additional Sibling Information

Insurance Information

Name of Primary Insurance Company:

Name of Subscriber on the Insurance Card:

Address of Primary Insurance Company:

Policy Effective Date:

Policy ID#:

Group ID#:

Subscriber’s Date of Birth:

Subscriber’s Home Address:

Subscriber’s phone number:

Subscriber’s Relation to Patient:

Subscriber’s Employer:

Add Additional Insurance Information

Responsibility for Payment for Services Rendered

By signing below, I hereby authorize Bloomington Pediatrics 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 co-insurance 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:

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:

Preferred Contact Name:

Preferred Method of Notifications From Our Practice

Phone Call Text Message Email

Enter Preferred Contact Phone Number or Email as Indicated Above:

You may opt out of notifications at any time by contacting the practice at 309-662-0504, opt. 3

Electronic Prescriptions: Our electronic medical record program accesses your prescription/medication history in order for us to safely prescribe your medication. By signing this form, you authorize us to do so.

Preferred Pharmacy Name:

Pharmacy Address:

Signature:

Date:

Immunizations: Our electronic medical record program allows for your immunization data to be sent directly to the I-CARE State of Illinois Registry. I-CARE allows your providers to obtain your immunization history to ensure your safety. Please indicate below if you authorize us to submit this data. If you wish to opt out, you will need to complete additional paperwork with our front desk receptionist.

My signature indicates the following preference for the immunization registry:

Opt IN Opt OUT

Signature:

Date:

Consent to Medical Treatment

I hereby certify that I am the parent or legal guardian of the patient identified on this form. By signing below, I consent to and authorize the physicians, nurses, and other healthcare providers at Bloomington Pediatrics to provide treatment to my child, including, but not limited to: receiving a history of present illness, receiving disclosures of protected health information, and any and all healthcare examinations, treatment, diagnostic testing medication administration, immunizations or other medical treatment as deemed reasonably medically necessary by their professional judgment. I understand that there are risks with all medical treatments and procedures, and I understand that Bloomington Pediatrics cannot guarantee that any medical treatment will be successful or without complications such as serious illness, injury, or death.

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 for Other Adult Caregivers

By signing below, I hereby authorize, in addition to the legal guardians of the patient, the adult persons listed below may schedule and/or accompany the patient to their appointments, receive any and all protected health information about the patient and consent to the provision of medical care for the patient including, but not limited to: providing a history of present illness, any and all healthcare examinations, diagnostic testing, administration of immunizations, and any other medical treatment deemed reasonably medically necessary by Bloomington Pediatrics. This consent will expire upon the patient’s 18th birthday, at which time a new consent must be signed by the patient.

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.

Name of Other Adult Caregiver:

Relationship to patient:

Caregiver Phone Number:

Add Additional Adult Caregiver

Before the patient’s 18th birthday, the above authorization may be revoked or updated by notifying the practice either in person or in writing and a new authorization may be submitted. In situations of parental separation or divorce, legal documentation must be provided to validate single parent authority on medical decision making, or that a parent does not have legal access to the patient record or to make such changes. No action will be taken without court documentation to support the request.

Signature:

Date:

Your information will be encrypted.