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:

Primary 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 dedicated to delivering compassionate, high-quality care to every child and their family. Timely payment of your bill helps us maintain this commitment. Please review, sign, and return our Financial Policy before your treatment begins. A copy of this policy is available upon request.

Insurance: We accept most insurance plans and will file your insurance claims provided you supply a current copy of your insurance card and accurate information at each visit. You are responsible for any balance remaining after insurance contributions, which is due within 21 days of the statement date.
Copayments: Copayments are required at the time of service as part of your agreement with your insurance provider. Failure to make copayments at the time of service may be reported to your insurance for further action. Note: Patients with Medicaid as secondary insurance must still cover any primary insurance copayments, as Medicaid does not cover these.

Proof of Insurance: All patients must complete our patient information form and provide a copy of a valid driver’s license and insurance card to verify insurance.

Claims Submission: We will submit your insurance claims and assist you as much as possible to secure payment. Your insurance may request additional information from you directly, and it is your responsibility to provide this. Ultimately, the balance of your account is your responsibility, regardless of insurance payment.

Coverage Changes: Please inform us of any insurance changes before your next visit to ensure you receive your full benefits. If your insurance does not pay within 45 days, the balance will be billed to you.

Nonpayment: Balances are due within 21 days of the statement. If unpaid, reminders will be sent at timely intervals. Failure to settle your account or contact our office for payment arrangements will lead to referral to a collection agency and possible dismissal from the clinic. We offer a 90-day credit period, during which you must pay one-third of your balance or make alternative arrangements with our business office.

No Shows: Missed appointments are tracked, and multiple no-shows may result in dismissal from the clinic.

Payment Methods: We accept all major credit cards, debit cards, cash, checks, and money orders. Credit card payments can also be made over the phone. Returned checks will incur a $25 processing fee and may be referred to a third-party collection agency.

Please download the PDF version of our Financial Policy for your records and familiarize yourself with these guidelines to ensure a smooth experience at Arkansas Pediatric Clinic.

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. Who is authorized to disclose the information? Arkansas Pediatric Clinic

2. Who is authorized to receive the information?

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

Add new row

4. The information is needed for:

Add new row

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.

10. I understand that I may receive personal health information via email and I understand that the email containing the requested information is unencrypted.

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.