Please fill the sections carefully and ensure that all sections are filled. .Please ensure that there are no errors made in filling the form, as this could lead to non payment by insurance companies.
CONSENT FOR CARE
I hereby give my consent for treatment at Germantown Pediatric and Family Medicine .
Consent for Well Child Policy
The Benefits of Well-Child Visits:
Prevention. Your child gets scheduled immunizations to prevent illness. You also can ask your pediatrician about nutrition and safety in the home and at school.
• Tracking growth and development. See how much your child has grown in the time since your last visit, and talk with your doctor about your child's development. You can discuss your child's milestones, social behaviors and learning.
• Raising concerns. Make a list of topics you want to talk about with your child's pediatrician such as development, behavior, sleep, eating or getting along with other family members. Bring your top three to five questions or concerns with you to talk with your pediatrician at the start of the visit.
• Team approach. Regular visits create strong, trustworthy relationships among pediatrician, parent and child. The AAP recommends well-child visits as a way for pediatricians and parents to serve the needs of children. This team approach helps develop optimal physical, mental and social health of a child.
Patients from birth through age 21 are required to have a complete physical examination per the guidelines of the American Academy of Pediatrics to participate in our practice.
We firmly believe in the effectiveness of vaccines to prevent serious illness and to save lives.
We firmly believe in the safety of our vaccines.
We firmly believe that all children and young adults should receive all of the recommended vaccines according to the schedule published by the Centers for Disease Control and Prevention and the American Academy of Pediatrics.
We firmly believe, based on all available literature, evidence, and current studies, that vaccines do not cause autism or other developmental disabilities.
We firmly believe that thimerosal, a preservative that has been in vaccines for decades and remains in some vaccines, does not cause autism or other developmental disabilities.
We firmly believe that vaccinating children and young adults may be the single most important health-promoting intervention we perform as healthcare providers, and that you can perform as parents/caregivers.
The recommended vaccines and the vaccine schedule are the results of years and years of scientific study and data gathering on millions of children by thousands of our brightest scientists and physicians.
This said, we recognize that there has always been and will likely always be controversy surrounding vaccination. Indeed, Benjamin Franklin, persuaded by his brother, was opposed to smallpox vaccine until scientific data convinced him otherwise. Tragically, he had delayed inoculating his favorite son Franky. The boy contracted smallpox and died at the age of 4 leaving Franklin with a lifetime of guilt and remorse. In his autobiography, Franklin wrote: “In 1736, I lost one of my sons, a fine boy of four years old, by the smallpox...I long regretted bitterly, and still regret that I had not given it to him by inoculation. This I mention for the sake of parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it, my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen.”
The vaccine campaign is truly a victim of its own success. It is precisely because vaccines are so effective at preventing illness that we are even discussing whether or not they should be given. Because of vaccines, many of you have never seen a child with polio, tetanus, whooping cough, bacterial meningitis, or even chickenpox, or known a friend or family member whose child died of one of these diseases. Such success can make us complacent or even lazy about vaccinating. But such an attitude, if it becomes widespread, can only lead to tragic results.
After publication of an unfounded accusation (later retracted) that MMR vaccine caused autism in 1998, many Europeans chose not to vaccinate their children. As a result of under immunization, Europe experienced large outbreaks of measles, with several deaths from disease complications. In 2012, there were more than 48,000 cases of pertussis (whooping cough) in the United States, resulting in 22 deaths. Most victims were infants younger than six months of age. Many children who contracted the illness had parents who made a conscious decision not to vaccinate.
When you don’t vaccinate, you take a significant risk with your child’s health and the health of others around them. By not vaccinating, you also take selfish advantage of thousands of others who do vaccinate their children, thereby decreasing the likelihood that your child will contract a vaccine preventable disease. We feel that refusing to vaccinate is self-centered and unacceptable. We are making you aware of these facts not to scare you or coerce you, but to emphasize the importance of vaccinating your child. We recognize that the choice may be a very emotional one for some parents. We will do everything we can to convince you that vaccinating according to the schedule is the right thing to do. However, should you have doubts, please discuss these with your healthcare provider in advance of your visit. In some cases, we may alter the schedule to accommodate parental concerns or reservations. Please be advised, however, that delaying or “breaking up the vaccines” to give one or two at a time over two or more visits goes against expert recommendations, and can put your child at risk for serious illness (or even death) and goes against our medical advice as providers at Germantown Pediatrics and Family Medicine.
Because we are committed to protecting the health of your children through vaccination, we require all of our patients to be vaccinated. Infants will receive all age-appropriate recommended vaccines by three months of age, with additional recommended vaccines as well as booster doses by two years of age. Children will receive additional recommended booster doses by the time they are seven years old, and will be given recommended 11–12-year preteen vaccinations by the time they are 13 years old. We will complete 16-year teen vaccinations before each child’s 17th birthday.
We do not keep a list of such providers, nor would we recommend any such physician. Please recognize that by not vaccinating, you are putting your child at unnecessary risk for life-threatening illness and disability, and even death. As medical professionals, we feel very strongly that vaccinating your child on schedule with currently available vaccines is absolutely the right thing to do to protect all children and young adults. Thank you for taking the time to read this policy.
I hereby authorize payment to Germantown Pediatrics and Family Medicine for services rendered to me or my dependents. I hereby authorize release of information necessary to expedite the claim process.
LIFETIME AUTHORIZATION TO FILE MEDICARE
I request the payment of authorized Medicare benefits to be made either to me or on my behalf to Germantown Pediatrics and Family Medicine for services furnished at the clinic. I also authorize any holder of medical information about me to release to the Center for Medicare/Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services.
When scheduling an appointment, we will make every attempt to verify your insurance and eligibility prior to checking in. Your insurance policy is a contract between you and your insurance company
It is your responsibility to notify us of any changes to your insurance.
We need to see your insurance card and ID at every visit.
You are responsible for verifying your insurance coverage, which includes, but is not limited to co-insurance, copayments, deductibles, and verification of what is covered ( in house labs, preventive care visits, etc). You are responsible for any payments that are not covered by your insurance or that your insurance assigns as your responsibility.
Germantown Pediatrics and Family Medicine will bill my insurance carrier based on the information provided above. I am responsible for I agree to pay any outstanding charges should be account be turned over to an outside collection agency. Germantown Pediatrics and Family Medicine will bill my insurance carrier. However, I understand and agree that I am responsible for payment of all charges for services provided, regardless of any insurance coverage(s).
RETURNED CHECK FEE
We assign a fee of $50 for any returned checks, and will not allow you to write any future checks.
NO-SHOW/LATE CANCELLATION POLICY
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY!
Effective date: January 2021
The Practice of Germantown Pediatric and Family Medicine is required by applicable federal and state laws to maintain the privacy of your health information. Protected health information (PHI) is the information we create and maintain in the course of providing our services to you. Such information may include documentation of your symptoms, examination and test results, diagnoses and treatment protocols. It also may include billing documents for those services. We are permitted by federal privacy law (the Health Insurance Portability & Accountability Act of 1996 (HIPAA), to use and disclose your PHI, without your written authorization, for purposes of treatment, payment, and health care operations. Your Health Information can be used for payment purposes, for treatment purposes, and for health care operation purposes.
Your Health Information Rights
The health and billing records we maintain are the physical property of the Practice. The information in them, however, belongs to you. You have a right to:
The Practice is required to:
We reserve the right to amend, change, or eliminate provisions of our privacy practices and to enact new provisions regarding the PHI we maintain about you. If our information practices change, we will amend our Notice. You are entitled to receive a copy of the revised Notice upon request by phone or by visiting our website or Practice.
Other Uses and Disclosures of your PHI
As Required by Law
Law Enforcement and Correctional Institutions.
Health Oversight Federal law may require us to release your PHI to appropriate health oversight agencies .
Judicial/Administrative Proceedings -We may disclose your PHI with your authorization, or as directed by a proper court order.
For Specialized Governmental Functions or Serious Threat
Coroners, Medical Examiners, and Funeral Directors
Other uses and disclosures of your PHI not described in this Notice will only be made with your authorization, unless otherwise permitted or required by law.
To Request Information, Exercise a Patient Right, or File a Complaint
If you have questions, would like additional information, want to exercise a Patient Right described above, or believe your (or someone else’s) privacy rights have been violated, you may contact the Practice’s Privacy Officer at 901-854-5455, or in writing to us at our practice address.
Please note that all complaints must be submitted in writing to the Privacy Officer at the above address. You may also file a complaint with the Secretary of Health and Human Services (HHS), Office for Civil Rights (OCR). Your complaint must be filed in writing, either on paper or electronically, by mail, fax, or e-mail. The address for the Colorado regional office is: Office for Civil Rights, U.S. Department of Health and Human Services, 999 18th Street, Suite 417, Denver, CO 80202; or call (800) 368-1019. More information regarding the steps to file a complaint can be found at: www.hhs.gov/ocr/privacy/hipaa/complaints.
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