18 & Older Paperwork

Patient Profile 18 Years & Older

Please review and make any necessary changes to the information on this profile form

Patient Information:

Parent/Guardian Contact Information:

Primary Insurance information:

Other Contacts:

• Insurance coverage is a contract between you and your insurance company. It is your responsibility to know what your plan does and does not cover.
• We will file insurance claims for you , but you are responsible for amounts not paid by insurance. I also understand that all co-payments, deductibles, and co-insurance are due at the time of service.
• I authorize payment of medical benefits to be made directly to Pediatric & Adolescent Associates, PSC for services performed. I further agree to be fully responsible for all lawful debts incurred for services provided.
• We will only file secondary insurance for those who have Medicaid, WellCare or Coventry Care of Kentucky as their secondary insurance. You are responsible for filing all other secondary insurance.
• I consent to be contacted by regular mail, email or by telephone (including a cell phone number) regarding any matter related to my account with Pediatric & Adolescent Associates, PSC.

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

Pediatric & Adolescent Associates, PSC Consent to Treat/ Medical Records/ Privacy 18 years & older

hereby authorize and consent to the examination and/or treatment during office and facility visits by the physicians and clinical staff of Pediatric & Adolescent Associates.

By signing below, I authorize Pediatric & Adolescent Associates to release my medical and billing information to:

If there is ever a change in this request, please notify the staff of Pediatric & Adolescent Associates.

By signing below, I authorize the following individuals to request prescription refills on my behalf, pick up prescriptions, x-rays, etc on my behalf:

Medical Records/Privacy

At Pediatric & Adolescent Associates, we are committed to protecting the security and privacy of your personal information. Medical records are the property of P AA, kept in a secure location, and are accessed for only purposes outlined by the Notice of Privacy Practices. Records may be released or shared with other health care providers for your treatment. Patients are entitled to one free copy of their medical records only after an authorization for release is signed.

• I have received a copy or been made aware I may have access of a copy, of the updated Notice of Privacy Practices from Pediatric & Adolescent Associates.
• I understand that PAA, its attorney and/or its agents including collection agencies may call my home, cell phone & place of employment for healthcare reasons, appointment reminders and to resolve billing issues.
• I understand that PAA, its attorney and/or its agents including collection agencies may contact me through email if I provide my email address at any time.
• I understand that PAA may use postcards to notify me of appointments or other pertinent information.
• I understand that PAA may fax immunization certificates, school excuses, physical/sports forms, and/or medication instructions to my personal or work fax, or may mail to my home. PAA cannot fax or send these documents to third parties (schools, daycares, etc.) without a separate, signed authorization form.
• I understand that P AA may leave messages on my answering machine regarding appointments and limited lab information.
• I understand that PAA may discuss patient information with adults or other minors present during the visit.
• I understand and agree to all of the above unless I strike through one of the statements.

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

FINANCIAL POLICY 18 & Older

Thank you for choosing Pediatric & Adolescent Associates, PSC as your pediatric primary care provider. The following is a statement of our Financial Policy, which we require you to sign prior to any treatment. All patients/parents must complete this form prior to seeing the Pediatrician.

We are committed to providing excellent medical care at a fair and reasonable price. Our staff will be happy to discuss any fees or financial issues in advance or at the time of your visit. We will make every effort to work with you to file insurance claims and timely resolve any outstanding balances.

Insurance: Each insurance policy is individual and it is the member's responsibility to fully understand their benefits, eligibility dates, and what is covered or not covered by your insurance. If the insurance company has not processed and paid the claim within 90 days, then payment of the account will become the responsibility of the parent/legal guardian. In the event of a separation/divorce, the parent bringing the child for the appointment is responsible for payment.

Demographic Information & Insurance Cards: It is extremely important that we have updated demographic data from both parents so that we will be able to contact you in the future. We also must have a current copy of your insurance card on file at all times. If your insurance changes, it is your responsibility to let us know as soon as possible and to inform us of the effective dates for your new policy. If prior encounters need to be refiled to a different insurance, you must notify us immediately due to Timely Filing requirements by your insurance. If we do not have your updated insurance information, then your claims may be denied for timely filing by your insurance and those claims would become your financial responsibility.

Network Providers: It is your responsibility to know if your physician is considered "In-network" by your insurance. Please call your insurance to verify and contact our Business Office, if there is any question regarding network eligibility.

Co-pays, Co-Insurances & Deductibles: I understand that any co-payments, deductibles, and co-insurances are due from me at the time of service. I understand that I am responsible for any balance not covered by my insurance.

Returned Checks: I understand that I will be charged an additional fee of $25 for any returned check.

Weekends/After Hours: I understand that there is an additional fee for appointments on late evenings, weekends and holidays that may or may not be covered by my insurance.

Cancellation of Appointments: As a courtesy to other patients and the physicians, we require an advance notice prior to canceling appointments. Please call us if you are unable to keep your appointment. There may be a fee for failure to notify us in advance.

Payment: We accept Cash, Check, Money Orders, Mastercard, Visa, American Express, Discover and Debit Cards for payment. You may be contacted by our office at any of your contact numbers listed to attempt to resolve any outstanding balances. In the event that the account is not resolved, I understand that my account may be turned over to a collection agency and my child/children will be terminated as patients of Pediatric & Adolescent Associates, PSC.

Assignment of Benefits/Authorization: I authorize payment of medical benefits to be made directly to Pediatric & Adolescent Associates, PSC for services rendered. I further agree to be fully responsible for all lawful debts incurred for services provided.

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

** Additional information on our financial policies can be found on our website at www.paalex.com.

** Business Office Direct Line: (859) 276-2005