Medrano Registration Forms

Date:

Patient Name:

Relationship to Guarantor:

Date of Birth:

Sex:

M F

Social Security Number:

Home Address:

City:

State:

Zip Code:

Home Telephone:

Referred By:

Pharmacy of Choice:

Pharmacy Address:

Pharmacy Phone Number:

Sibling Name:

Sex:

Date of Birth:

Health Condition:

Add new row for another sibling

Father's Name:

Date of Birth:

Home Address: (if different)

City:

State:

Zip Code:

Home Telephone:

Work Telephone:

Cell Phone:

Employer:

Employer Address:

Social Security Number:

Marital Status:

Mother's Name:

Date of Birth:

Home Address: (if different)

City:

State:

Zip Code:

Home Telephone:

Work Telephone:

Cell Phone:

Employer:

Employer Address:

Social Security Number:

Marital Status:

INSURANCE INFORMATION

Primary Insurance Name:

Effective Date:

Address:

City:

State:

Zip Code:

Telephone Number:

ID Number:

Group Number:

Full Name of Insured:

Policy Type:

HMO

PPO

PPC

Other

If Other, please specify:

Previous Physician:

Do you have a secondary insurance?

Yes No

Do you have Chip or Medicaid?

Yes No

NOTIFY IN CASE OF EMERGENCY!!

Name:

Relationship:

Phone:

Name:

Relationship:

Phone:

I hereby grant permission to Jaime Medrano MD PA to give and/or leave information regarding appointment times, test results or other information over the telephone and/or answering machine.

I understand that payment of all medical care is due at the time of service. In case of divorced parents, responsibility and payment shall be that of the guardian bringing the child in for treatment. I understand that it is my responsibility to pay any deductible, co-insurance or any other balance not paid by my insurance company. I understand that I am responsible for any costs incurred in the collection of patients account in case of default, including reasonable attorney fees and court costs.

I hereby grant permission to Jaime Medrano MD PA to release any pertinent information to my insurance company upon request, and I also authorize payment directly to Jaime Medrano MD PA. A photo static copy of this authorization shall be considered as effective and valid as the original.

Name (Signature):

Date:

Witness:

Office Policy

Patient Name:

Please note the following:
• We ask that you be at the office at or before your appointment time.
**Late arrivals may need to be rescheduled and will be considered a "no-show" appointment**
• Please bring your photo ID and a valid, current Insurance card/Medicaid letter to each appointment.
• Please bring your child's vaccine record to each well visit.
• All appointments must be canceled by the end of the business day the day before the appointment. (For ex. If the appointment is scheduled for Monday morning at 11:00 a.m, the appointment would need to be canceled by closing time on Friday.) Please remember that courtesy calls are not guaranteed and you will still be responsible for attending your appointment if we are unable to confirm the appointments.
• There will be a fee of $10.00 for each copy of immunization records provided by our office.
• There will be a $35.00 fee for all sports/camp/daycare/school forms brought in outside of a visit. This fee is due at the time of pickup and a 72 business hour turnaround is required for any paperwork that requires Signature or review from a provider. Any paperwork brought in during a scheduled appointment will be completed at no charge. Any paperwork for siblings will require a separate visit.
• There is a $25.00 fee for all FMLA paperwork. This paperwork requires a minimum of 72 business hours depending on the complexity of the forms.
• Personal copies of patient medical records start at $25.00. This fee will cover the first 20 pages. After those 20 pages, there will be a $0.50 charge per page.
• There will be a $5.00 charge for each controlled med refill filled outside of a visit.

Initials required

Initials:

1. Your insurance policy is a contract between you, your employer and the insurance company. We are NOT a party to that contract. Our relationship is with you, not your insurance company. We cannot become involved in disputes between you and your insurance regarding "usual and customary" charges. Our involvement will be limited to supplying factual information to facilitate claim processing.

Initials:

2. All charges are your responsibility whether your insurance pays or does not pay. Not all services are a covered benefit in your medical plan. Some insurance companies arbitrarily select certain services they will not cover, i.e. vision screening, audiology testing, circumcision or certain vaccines.

Initials:

3. Fees for services, along with unpaid deductibles and co-payments are due at the time of service. We accept cash, Visa, Master Card, and Discover. Patients with outstanding balances must have a payment arrangement on file to be seen in clinic.

Initials:

4. If your insurance company does not pay the claim within 45 days, it is your responsibility to contact your insurer to expedite payment.

Initials:

5. All patients will be self-pay if insurance is unable to be verified or shows that the patient is ineligible and must sign the self-pay agreement
before being seen in clinic.

Initials:

6. Please note that patients with multiple no shows will be dismissed from clinic.

Initials:

7. Your child's assigned PCP with your insurance plan must be one of the Jaime Medrano MD PA here before your child may be seen in clinic. Failure to update the PCP with your insurance before your child's appointment may result in having to reschedule the visit.

Initials:

8. Jaime Medrano MD PA will file claims to the insurance currently on file. It is your responsibility to update the insurance information as needed to ensure accurate filing. This includes adding a secondary insurance to your child's chart.

Initials:

9. We understand that temporary financial problems may affect timely payments of your balance. We encourage you to communicate any such problems to us, so that we may assist you to keep your account in good standing. These policies have been implemented to better our care to you and your family and in effort to reduce wait times. Thank you for your cooperation and understanding.

Parent Name (Signature):

Date:

Authorized Contacts

Date:

Patient Name:

Date of Birth:

Mother's Name:

Father's Name:

Status:

Married Separated Divorced Other

If Other, please specify:

Please remember to protect the privacy of your child we must have your written consent to evaluate and treat your child during each visit. Please list the following information for each of the individuals you are authorizing to accompany your child to visits including but not limited to sick visits, well child checkups. nurse visits, etc. This authorization also gives us consent to release any information regarding your child's health and/or treatment to the below individuals including appointment times and diagnosis. In addition, we ask that you provide copies of any applicable legal custody paper, orders, medical authorizations, etc. to our office. Please note that we cannot prevent a biological parent or legal guardian from receiving information or accompanying his/her child to a visit without legal documentation.

**This form overrides all authorization or consents submitted previously.

Name:

Relationship to child:

Date of Birth:

Address:

Phone Number:

Add new row for another authorized individual

*Please note photo identification will be requested.

I understand that my child(ren)'s records are protected under the Federal Confidentiality Regulations and cannot be disclosed without my written authorization unless otherwise provided for in the regulations. I also understand that this authorization may be revoked in writing at any time and that the disclosed information may be subject to disclosure by the recipient although discouraged.

Prohibition on Re-disclosure: This information has been disclosed from records whose confidentiality is protected by federal law. Federal regulations (42CPRPart2) prohibit recipients from making any further disclosure of the information except with the specific written consent of the patient. A general authorization for the release of information if held by another party is not sufficient for that purpose.

Those listed above have my permission to accompany my child to Jaime Medrano MD PA. In addition, the above-named individuals have my permission to receive all pertinent health information regarding my child from Jaime Medrano MD PA. This authorization shall remain valid until written notice to the contrary is received.

Signature:

Relationship to child:

Date:

Assignment of Benefits & Authorization to Release Information

I hereby authorize payment to this clinic of all benefits specified and otherwise payable to me for any services rendered by the clinic on or after this date and for such other charges as may be made by this clinic.

I hereby agree to pay the same and also agree that in the event that payment by a third party for any individual visit exceeds that necessary to cover charges incurred during that visit, any coverage may be applied to outstanding charges owed by the clinic for other services rendered to myself, my spouse, or legal dependents of myself or spouse at the time.

I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or any insurance carriers all information needed for the completion of all medical claims. I understand that the information to be released may include information pertaining to mental- or psychiatric-related conditions and/or drug or alcohol abuse. A copy of this authorization shall be as valid as the original.

I also understand that this authorization gives permission to transmit the requested records electronically, including the electronic submission of claims to your insurance company. If another party receives them in error, I absolve this clinic and the employees of this clinic of any and all liabilities relating to such submission of said records.

I certify that I have read the foregoing and am the patient or the patient's duly authorized agent to execute the above and accept its terms.

Patient Name:

Signature of Patient or Authorized Agent:

Witness:

Date:

Prohibition on Re-disclosure: This information has been disclosed from records whose confidentiality is protected by federal law. Federal regulations (42CPRPart2) prohibit recipients from making any further disclosure of the information except with the specific written consent of the patient. A general authorization for the release of information if held by another party is not sufficient for that purpose.

PROVIDER NOTICE OF INFORMATION PRACTICES

Patient Name:

Date:

Uses and Disclosures of Health Information
We use health information about you for treatment, to obtain payment for treatment, for administrative purposes and to evaluate the quality of care that you receive.

We may disclose identifiable health information about you without your authorization for several other reasons. Subject to certain requirements, we may give out health information without your authorization for public health purposes, for auditing purposes, for research studies, and for emergencies. We provide information when otherwise required by law, such as for law enforcement in specific circumstances. In any other situation, we will ask you for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information. you can later revoke that authorization to stop any future uses and disclosures.

We may change our policies at any time. Before we make a significant change in our policies. we will change our notice and post the new in the waiting area and in each examination room. You can also request a copy of our notice at any time. For more information about our privacy practices, contact the person listed below.

Individual Rights
You may request in writing that we not disclose your information for treatment, payment and administrative purposes except when specifically authorized by you when required by law or in emergency circumstances. We will consider your request but are not legally required to accept it.

Complaints
If you are concerned that we have violated your privacy rights or you disagree with a decision we made about access to your records, you may contact the person listed below. You also may send a written complaint to the U.S. Department and Human Services. The person listed below can provide you with the appropriate address upon request.

Our Legal Duty
We are required by law to protect the privacy of your information, provide this notice about our information practices and follow the information practices that are in this notice.

If you have any questions or complaints, please contact:
Rick Hidalgo, CMPE
Administrator
415 S. Airport Dr. Ste. E
Weslaco, TX 78596
P: 956-973-5024

I hereby acknowledge that I have received the provider notice of information practices from Jaime Medrano MD PA.

Parent Name (Signature):

Date:

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

Your information will be encrypted.