2024 Demographics - Newborn to Age 18 - Indianapolis Independent Pediatricians, PC

Patient Name First

Last Name

Date of Birth

Preferred Name

Street Address

City

Zip Code

Lives With

Mom

Dad

Other/Foster

PARENT/GUARDIAN INFORMATION: NOTE: Courtesy Appointment Reminders are sent to Parent/Guardian #1. Please either call office or send us a secure email through our website if the number changes. Thank you.

Parent #1 First & Last Name

Date of Birth

Social Security #

Street Address (If same as patient indicate SAME)

City

Zip Code

Parent #1 Email address

Cell Phone/Main

Work Phone/Other

Employer Name

Parent #2 First & Last Name

Date of Birth

Social Security #

Street Address (If same as patient indicate SAME)

City

Zip Code

Email address

Cell Phone/Main

Work Phone/Other

Employer Name

YES

CONSENT TO TREAT

I give the physicians of Indianapolis Independent Pediatricians consent to provide and perform medical care, tests, procedures, and administer medications and vaccines considered necessary or beneficial for my child’s health and well being. I acknowledge that no representations, warranties or guarantees as to the results or cures have been made to me or relied upon by me.

YES

FINANCIAL RESPONSIBILITY & FINANCIAL CONSENT:

By checking YES, I confirm that all personal information is correct and I verify that I have provided the most current/accurate insurance information for my child. I understand I may request a goodwill estimate of my charges for non-urgent services. I authorize the release of any information regarding my child’s exam and treatment for the purpose of obtaining insurance compensation, precertification or medical records. I authorize payment of medical benefits for services rendered by the physicians of Indianapolis Independent Pediatricians. I acknowledge I have read and understand the Insurance Information /Financial Responsibility and Financial Policy for Indianapolis Independent Pediatricians. I understand a personal copy is available to me at any time upon my request, available online at www.indypeds.com, and posted in the office. In addition, in the event IIP has to pursue a collection action against me, I understand that in addition to my financial responsibility for the medical services provided, I will be responsible for all cost of collection including but not limited to interest charges allowed at the current legal rate, attorney fees and court costs.

*A $35 no show fee will be applied towards any missed, late cancelled, or rescheduled appointments. The no show fee is any appointment missed, late cancelled or rescheduled without a 24-hour notice. Please note the courtesy text message reminder system does not accept late cancellations. This fee is not covered by your insurance and will need to be paid prior to rescheduling.

YES

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I have read and understand the Notice of Privacy Practices. I understand a personal copy is available to me at any time upon my request, available online at www.indypeds.com, and located in the office.

YES

STANDARDS AND DISMISSAL POLICY

Any established patient who fails 3 appointments is cause for dismissal. This will include all siblings.
All appointments must be confirmed, cancelled or rescheduled 24-hours in advance. A late cancel or same day cancel is a no show. Late arrival for an appointment is considered a no show.
Text messages courtesy reminders are sent via our scheduling system and may not be received by your carrier and your response may not be transferred back to our office. I understand I am responsible to know when an appointment is scheduled and will call back if another outreach is kindly made by the office to confirm the appointment.
Any new patient who fails to keep their New Patient appointment is cause for dismissal at the discretion of the practice.
Any patient/parent who is non-compliant with appointments, advice or medications is cause for dismissal at the doctor’s discretion.
Any patient/parent who fails to meet their financial obligation is cause for dismissal.
Any patient/parent who are rude, disrespectful, or behaves in an abusive or threatening manner, either verbal or physical, will be dismissed.

EMERGENCY: Please list someone OTHER than parent/guardian.

Emergency Contact

Relationship

Emergency Contact Phone

IN MY ABSENCE - Authorization to Consent for Medical Treatment & Release of Protected Health

Name

Relationship

Phone

Name

Relationship

Phone

YES

You represent that you are permitted to receive calls, text messages, and emails at the information you have provided and agree to promptly alert us whenever this information changes. Our office may also make contact with others you have indicated and you agree to promptly alert us whenever this information changes.

Parent/Guardian Electronic Signature

Date

Your information will be encrypted.