Patient Information Sheet

Today’s Date:

Patient’s Birthdate:

First Name:

Middle Initial:

Last Name:

Preferred Name:

Gender Assigned at Birth:

Male Female

Gender Identity:

Male Female Non-Binary Transgender Prefer not to report

Pronouns:

He/Him/His She/Her/Hers They/Them/Their

Sexual Orientation:

Hetrosexual Bisexual Homosexual Prefer not to report

Gender Identity / Sexual Orientation Privacy Status:

Private Public

Address:

House number/Street name:

City:

State:

Zip Code:

Primary Phone:

Secondary Phone:

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

Primary Email Address:

Secondary Email Address:

Preferred Method of Notifications From Our Practice

Phone Call Text Message Email

Parent/Guardian Names:

First name:

Last name:

Relationship to Patient:

Mother Father Stepmother Stepfather Other

If Other, Please Specify:

Last name:

First name:

Relationship to Patient:

Mother Father Stepmother Stepfather Other

If Other, Please Specify:

Ethnicity:

Non-Hispanic Hispanic Prefer not to report

Primary race : (choose all that apply)

White

Asian

African American/Black

Other Pacific Islander

Native American

Native Hawaiian

Other Race

Prefer not to report

Preferred language:

English Spanish Other

If other, please specify:

Interpreter Needed?

Yes No

Preferred Pharmacy

Name:

Address:

City:

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.

Signature:

Date:

Immunization Registry

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:

Insured Subscriber / Responsible Party Information

Name of Primary Insurance Company:

ID#:

Group#:

Name of Subscriber on the Insurance Card:

Subscriber’s Date of Birth:

Subscriber’s address, if different from patient:

Subscriber’s phone number:

Subscriber’s Employer:

Name of Secondary Insurance Company:

ID#:

Group#:

Name of Subscriber on the Insurance Card:

Subscriber’s Date of Birth:

Subscriber’s address, if different from patient:

Subscriber’s phone number:

Subscriber’s Employer:

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.

In addition to the legal guardians of the patient, the persons below are authorized to schedule and/or accompany the patient to their appointments, consent to recommended medical care, and receive health information about the patient. This consent will expire upon the patient’s 18th birthday, at which time a new consent must be signed.

Name:

Relationship to patient:

Add new row for another legal guardian

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.