CMC English New Patient Paperwork

Please correct the errors described below.

Welcome to Children's Medical Clinics of East Texas!

Dr. C. Turner Lewis, III MD, the Pediatric Nurse Practitioners and CMC Staff are here to provide you with access to quality, compassionate, and complete family centered care. Our goal is to serve you and your family ensuring your child's health care needs are met while striving to provide top-notch customer service. We will continue to develop a trusting relationship with our patient and families, creating an environment where parents feel confident in our care and patients experience a trusting relationship.

Our clinics provide many services to meet your child's healthcare needs. One important service is the annual Well Child Visit. As per the American Academy of Pediatrics, a gowned exam is recommended in order to perfonn a complete assessment. We understand this may be new for your child. We appreciate your role as a caregiver in preparing your child or teenager for their clinic visit. Please keep in mind it is our #1 goal to ensbre the health and well ness of your child. One step in doing this is to perfonn a thorough health assessment each year.

In addition, a top focus of the CMC Staff is on prevention of illness and injury and promotion of healthy lifestyles behaviors. Each Well Child Visit will include risk assessments and screening tools appropriate for your child's age. This may include screening labs such as blood and urine tests, immunizations, and risk questionnaires. Follow-up appointments may also be needed to discuss these results.

There are many developmental stages in the life of a child from infancy to young adult. Each developmental milestone brings different healthcare needs for the child and development concerns. It is important that we encourage your child to be an active participant in meeting these needs. This may include one on one time between your child and provider, especially as the child reaches pre-adolescent and adolescent years. Parents are advised to remain during all physical assessments, but may be asked to leave the room for a brief time during the Well Child Visit. This time is to provide an open, trusting and safe environment in which the child will have an opportunity to speak with the provider one on one. Building a strong therapeutic relationship with the children and adolescents supports their ability to become responsible and accountable for their healthy lifestyle choices.

Your child's health is our primary responsibility as we work in joint collaboration with you as parents. We look forward to playing an active role with your family as we foster an environment of health and wellness and a commitment to quality service.

We thank you for entrusting us with the privilege to care for your child's health and well being.

Children's Medical Clinics of East Texas

PATIENT INFORMATION

ALL FIELDS MUST BE COMPLETELY FILLED OUT!

RESPONSIBLE PARTY (PERSON WHO IS RESPONSIBLE FOR THE PATIENT'S ACCOUNT)

MOTHER'S INFORMATION

FATHER'S INFORMATION

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:

(THIS INCLUDES STEP PARENTS, GRANDPARENTS & ANY CARE TAKERS WHO CAN HAVE ACCESS TO THIS PATIENT'S RECORDS):

INSURANCE INFORMATION

I HEREBY STATE THAT ALL OF THE ABOVE INFORMATION IS TRUE AND CORRECT.

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

NO SHOW POLICY ACKNOWLEDGEMENT

Our office understands that situations arise that may prevent you from attending your child's study; a notice of cancellation in advance allows us the opportunity to offer the appointment to other patients who need medical attention.

In order to improve access and care for all patients, the failure to cancel or reschedule an appointment 24 hours before your appointment, will result in a "No Show" ("No Show") and will be subject to a fee Non-refundable $ 25 is not covered by your insurance. This charge will be charged to the patient and must be paid before the next appointment. If Multiple "No Show" or ("No Show") are presented, it may result in the need to transfer your medical attention to another provider.

PREFERRED METHOD OF COMMUNICATION

DELEGATION OF CONSENT

We understand that sometimes there are occasions in which some other relative who is not the guardian/parents of the patient indicated in the patient's medical record brings the child to receive medical attention. Below, please indicate to anyone who has your authorization to accompany the patient when you are not available.

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I authorize the aforementioned individuals to consent to any medical / treatment decisions necessary at the time of consultation and to have access to the patient's medical record at Children's Medical Clinics. This Consent Delegation is valid until it is withdrawn.

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

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/LIMITED AUTHORIZATION & RELEASE FORM

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.

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

I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA ALL OF THE MEANS LISTED BELOW:

  • Cell Phone Confirmation
  • Home Phone Confirmation
  • Work Phone Confirmation
  • Text Message to my Cell Phone
  • Email Confirmation
  • Clinic's Secure Web Patient Portal

I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA ALL OF THE MEANS LISTED BELOW:

  • Cell Phone Confirmation
  • Home Phone Confirmation
  • Work Phone Confirmation
  • Clinic's Secure Web Patient Portal

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.

Office USE Only

As Privacy Officer, I obtained the patient's/Guardian or Patient (or legal representatives) signature on this Acknowledgement.

Signature of Privacy Officer: Martha Marshall

MEDICAL CONSENT

This facility has on staff Physicians and Nurse Practitioners to assist in the delivery of medical pediatric care.

A Nurse Practitioner is not a doctor. A Nurse Practitioner is a Registered Nurse who has received advanced education and training in the provision of health care. A Nurse Practitioner can diagnose, treat, and monitor common acute and chronic diseases as well as provide health maintenance care. In addition, the Nurse Practitioner may treat minor lacerations and other minor injuries.

A Physician or Nurse Practitioner may provide such medical services that are within his/her education, training and experience. These services may include:

  • Obtaining histories and performing physical exams.
  • Ordering and/or performing diagnostic and therapeutic procedures.
  • Formulating a working diagnosis.
  • Developing and implementing a treatment plan
  • Monitoring the effectiveness of therapeutic interventions.
  • Offering counseling and education.
  • Supplying sample medications and writing prescriptions.
  • Making appropriate referrals.
  • Developmental/Behavioral screenings using standardized tools adapted for your electronic health record such as ASQ-3, ASQ-SE, CRS-R, CRAFFT, DENVER II, M-CHAT, PEDS, PHQ-9, PSC-35,VANDERBIL T, & Y-PSC.

I have read the above, and hereby consent to the services of Physician or a Nurse Practitioner for my health care needs. I authorize an unclothed physical exam only when it is deemed medically necessary by the Physician or Nurse Practitioner.

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

PAYMENT POLICY

Thank you for choosing Children's Medical Clinics of East Texas. We are committed to improving and maintaining the health of the children residing in the communities we serve. In order to maintain this quality of care, Children's Medical Clinics of East Texas expects payment in full for all services. The parent/guardian of the patient is ultimately responsible for payment for these charges. As a courtesy, Children's Medical Clinics of East Texas will file a claim with the patient's insurance company if necessary information is provided. If payment is not received for the third party within 60 days from the date of service, the parent/guardian is also responsible for any charges that are not covered by the third-party payer: deductibles, co-payments and any other non-covered charges: These amounts are due at the time of service.

I hereby assign to Children's Medical Clinics of East Texas, any and all benefits and all interest and rights for services rendered under my insurance policies or any reimbursement or prepaid health care plan. I hereby promise to pay for all services rendered to me to the extent I am legally responsible for such payment. I understand I am responSible for all health insurance co-payments and deductibles at the time of service.

If I am a MEDICAID PATIENT, I understand that the services or items ┬Ěthat I request to be provided to me may not be covered under the Texas Medical Assistance Program as being reasonably and medically necessary for my care. I understand that the Texas Department of Human Services or its health insuring agent determines the medical necessity of the services or items that I request and receive. I also understand that I am responSible for payment of the services or items I request and receive if these services are determined not to be reasonable and medically necessary for my care. These amounts are due at the time of service.

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

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