New Patient Packet

Please Select One

New Patient Update Patient

Primary Care Provider

Bone

Hawkins

Sanders

Duke

Johnson

Montgomery

Sax

Patient Registration Information

Please complete ALL sections below!

Patient's Personal Information

First Name:

Last Name:

Preferred Name:

DOB:

Social Security #:

Phone:

Email address

Address:

City:

State:

Zip:

List all children who live in the household:

Add Children

Race

White

Native Hawaiian/Other Pacific Islander

African American

Asian

Native American Indian/ Alaskan

Other

Ethnicity (Origin):

Not Hispanic or Latino Hispanic or Latino

Preferred Language:

English

Spanish

Other

Parent/ Guardian 1

First Name:

Last Name:

Date of Birth:

Social Security #:

Home Phone:

Cell Phone:

Email address

Address:

City:

State:

Zip:

Employer Name:

Work Phone:

Parent/ Guardian 2

First Name:

Last Name:

Date of Birth:

Social Security #:

Home Phone:

Cell Phone:

Email address

Address:

City:

State:

Zip:

Employer Name:

Work Phone:

Patient's Insurance Information

If newborn, hospital of birth:

Primary Insurance Name:

Employer Name:

Phone #:

Address:

City:

State:

Zip:

Policy Holder:

Policy Holder Date of Birth:

Relationship:

Parent Self Other

Policy #:

Group #:

Copay:

Secondary Insurance Name:

Employer Name:

Phone #:

Address:

City:

State:

Zip:

Policy Holder:

Policy Holder Date of Birth:

Relationship:

Parent Self Other

Policy #:

Group #:

Copay:

Pharmacy Information

Pharmacy Name:

Phone Number:

Address:

City:

Emergency Contact Information

(Other than mom or dad)

Name:

Address:

City:

State:

Zip:

Home Phone

Cell Phone

Relationship to Child:

Birth to 6 Months New Intake

Vital Signs:

Weight:

Length:

HC:

Caretaker Temp:

Patient Name:

DOB:

Gender:

Age:

Name of person completing form:

Relationship to patient:

Home Phone Number:

Cell Phone Number:

Name of Pharmacy Used:

Is your child presently taking any medications?

YES NO

(List with dosage and prescribing physician’s name below)

Add Medication

BIRTH HISTORY

Birth Weight

Term Premature

If premature, Weeks:

Vaginal birth C-section

Blood Type:

Maternal Complications?

Yes No

Explain if Yes

Any problems after delivery?

Yes No

Explain if Yes

Was there any jaundice?

Yes No

Bilirubin level/s

If male, was he circumsized?

Yes No

Was the first Hep B given in the hospital?

Yes No

Was the newborn hearing screen passed?

Yes No

Any problems since discharge?

Yes No

Explain if Yes

FEEDINGS

Breastfeeding?

Yes No

Any problems?

Yes No

If yes, please explain:

Bottle feeding?

Yes No

If Yes, Name of formula:

How much?

Do you have any questions or concerns you would like to discuss today?

Yes No

Explain if yes

FAMILY HISTORY

Have any family members (including natural parents, grandparents, aunts, uncles, siblings) had any of the following?

ADD/ADHD

Relationship

Heart Disease < 55 yrs

Relationship

Allergies

Relationship

Mental Health Issues

Relationship

Asthma

Relationship

Seizure Disorder

Relationship

Diabetes

Relationship

Substance Abuse

Relationship

High Cholesterol

Relationship

Additional Family History:

SOCIAL HISTORY

List all children in the home

Add Name

What is the parent’s marital status?

Single Married Divorced Unmarried/Living Together

Does anyone in the home smoke?

Yes No

Explain if yes

Friends and Family Waiver

DOB:

authorize Arkansas Pediatric Clinic to share pertinent "Protected Health Information" with the person(s) listed below.

Please print clearly

Add Name

I understand that I can withdraw the above at any time, with written request. I also understand that it is my responsibility to ensure that my family member does not divulge or use the information in any way without discussing with me first.

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

Patient's Signature

Date:

Authorization for Alternate Consent

Form must be signed even if not adding names

Child's First Name:

Child's Last Name:

DOB:

I, (Please input Name below), am the parent/legal guardian of the above listed child.

(Parent or Legal Guardian’s Name)

I authorize Arkansas Pediatric Clinic to deliver necessary medical services to my child as determined appropriate by the physicians at Arkansas Pediatric Clinic, following receipt of written consent from any of the individuals listed below:

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I acknowledge and agree to pay for all charges incurred for services provided to my child by Arkansas Pediatric Clinic, based on the consent of any of the individuals named above. I understand and agree that this authorization will remain in effect until I provide a written notice of revocation to Arkansas Pediatric Clinic.

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

Printed Name of Parent/Legal Guardian

Signature of Parent/Legal Guardian

Date:

ARKANSAS MEDICAID PRIMARY CARE PHYSICIAN MANAGED CARE PROGRAM PRIMARY CARE PHYSICIAN SELECTION AND CHANGE FORM

Member Information:

First Name:

Last Name:

Middle Initial:

Medicaid ID#

Social Security #

Birth Date:

Mailing Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Email address

Requested New Doctor (Primary Care Provider):

Add Requested New Doctor

I have picked the three (3) physicians named below in order of my preference to be my primary care physician. I understand only one (1) of them will be my primary care physician.

Other; Please specify:

Signatures:

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

Member Signature (or Legal Guardian if a minor)

Printed Name of Member (or Legal Guardian if a minor)

Date:

Financial Policy

Thank you for choosing Arkansas Pediatric Clinic as your child’s healthcare provider. We are committed to providing compassionate, high-quality care to every child and family. To help us continue this commitment, we ask that all accounts remain current.

Insurance:
We accept most insurance plans and will file claims as a courtesy with current insurance information provided at each visit. Any balance remaining after insurance payment is the parent or guardian’s responsibility and is due within 21 days of the statement date.

Copayments:
Copayments are due at the time of service. Patients with Medicaid as secondary insurance are still responsible for primary insurance copayments, as Medicaid does not cover these balances. Proof of Insurance Patients must provide a valid insurance card and photo ID at each visit. Please notify our office of any insurance changes prior to your appointment.

Claims & Coverage:
We will assist with filing insurance claims; however, any information requested by your insurance company is your responsibility to provide. If insurance does not pay within 45 days, the balance will become the patient’s responsibility. Nonpayment Balances not paid within 21 days may receive additional billing notices. Accounts not resolved or placed on approved payment arrangements may be sent to collections and could result in dismissal from the clinic.

No-Show Policy:
Missed appointments are tracked. After three (3) no-show appointments, Arkansas Pediatric Clinic reserves the right to terminate the doctor-patient relationship for the family.

Late Arrivals Policy:
10-15 minutes late arrival – Provider Discretion
15+ minutes late arrival – Automatic Reschedule with next available appointment at any location.

We will do our best to accommodate late arrivals. Please ensure you arrive ON TIME for your appointment. We recommend allowing extra travel time for unforeseen circumstances like traffic, aiming to be at least 15 minutes early. If you are a New Patient and haven't filled out the online forms yet, please arrive at least 15 minutes early.

Payment Methods:
We accept cash, checks, money orders, debit cards, and all major credit cards. Returned checks are subject to a $25 fee. Please contact our office with any questions regarding your account or payment arrangements.

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

Parent/Guardian Signature

Date:

Medical records email address: medicalrecords@arped.org

AUTHORIZATION TO RELEASE HEALTH INFORMATION

ALL ELEMENTS ARE REQUIRED PRIOR TO INFORMATION BEING RELEASED

Patient Name:

Date of Birth:

1. Physician/Facility authorized to disclose the information?

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2. Who is authorized to receive the information?

Name: Arkansas Pediatric Clinic
Complete Address: 16115 Saint Vincent Way, Suite 320 Little Rock, AR 72223
Phone Number: 501-664-4117 | Fax Number: 501-664-1137

3. The specific information to be requested or released is:

Add new row

4. The information is needed for:

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5. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be disclosed and no longer protected by these regulations.

6. I understand that Arkansas Pediatric Clinic will be paid for the costs of copying the information to be released.

7. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits. I may inspect or obtain a copy of any information used/disclosed under this authorization.

8. I understand that I may revoke this authorization in writing at any time by delivering a copy of my revocation to Arkansas Pediatric Clinic except to the extent that action has been taken in reliance on this authorization. This authorization expires: One year from date signed.

9. I understand Arkansas Pediatric Clinic will release the requested information only to the entity listed above.

PLEASE PRESENT A COPY OF A PHOTO ID

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

Signature of Patient or Representative

Date:

Phone Number

Relationship to Patient

Witness

Date:

Your information will be encrypted.