New Patient Forms - English - Palm Beach Pediatric Hematology Oncology

PATIENT HISTORY

Date:

CHILD’S NAME:

DATE OF BIRTH:

What is the reason for your visit:

PRENATAL HISTORY

Full term Preterm/Weeks Gestation Vaginal C Section

If Preterm/Weeks Gestation, specify:

Birth weight:

Length:

Did child have any medical problems after birth (bleeding, bruising, Jaundice, anemia, low platelets)?

PATIENT’S PAST ILLNESSES

Has the child been given a diagnosis previously?

Yes No

Date:

Explain:

Have there been any hospitalizations?

Medical Problems:

Surgeries:

Yes No

Date:

Surgery:

Abnormal blood work counts (white cells, hemoglobin, platelets, coagulation?)

Yes No

Primary language spoken:

English Spanish Creole

LIST DAILY MEDICATIONS AND DOSES

Check if No Daily Medications

Add Medications and Doses

LIST ALL DRUG ALLERGIES

Check if No Drug Allergies

FAMILY HISTORY

Father (biological):

Age:

Medical problems:

Mother (biological):

Age:

Medical problems:

PLEASE LIST ANY HEMATOLOGIC (blood/cancer) DISORDER IN BLOOD RELATIVES:

REVIEW OF SYSTEMS/LIST RECENT COMPLAINTS:

Do you have any specific concerns about your child or specific problems you wish to discuss today? If so, please explain:

Pharmacy Name:

Pharmacy phone number:

Or address:

PATIENT REGISTRATION FORM

Patient Name:

Your Name/Relation to Patient:

Date of Birth:

Sex:

M F

Race:

Social Security Number:

Home Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Cell Phone:

Email:

Pediatrician (PCP):

Phone Number:

Pharmacy:

Location:

Phone:

Child’s Other Physician(s) (besides Pediatrician):

Father’s Name:

Date of Birth:

Home Address (if different from patient):

City:

State:

Zip Code:

Home Phone:

Work Phone:

Cell Phone:

Mother’s Name:

Date of Birth:

Home Address (if different from patient):

City:

State:

Zip Code:

INSURANCE INFORMATION

Insurance:

Policy Number:

Guarantor’s Name:

Date of Birth:

Relation to Patient:

NOTIFY IN CASE OF EMERGENCY

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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:

Date:

Witness:

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 Palm Beach Pediatric Hematology Oncology to release any pertinent information to my insurance company upon request, and I authorize payment directly to Palm Beach Pediatric Hematology Oncology. A photo static copy of this authorization shall be considered as effective and valid as the original.

AUTHORIZATION TO RELEASE MEDICAL RECORDS

Date:

Physician/Facility Name:

Address:

City:

State:

Zip Code:

Child’s Name:

Date of Birth:

I hereby authorize and request the complete Medical Record of the child listed above to be released to: Palm Beach Pediatric Hematology Oncology | Melissa S. Singer, M.D., PA | 12957 Palms West Drive, Suite 103 Loxahatchee Fl, 33470-4989 | 561-798-9119 (office) | 561-798-9193 (fax)

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 Parent / Legal Guardian

Date:

**This consent for disclosure of medical information will be honored for the request only and will not be transferable for any additional information without the express written consent of the patient. It expires immediately upon completion of this action. I understand I may revoke this consent at any time except to the extent that the action has been taken in reliance on my consent. No other disclosure to other parties by release is permitted without the express written consent of the parent/legal guardian/patient. I have read and fully understand the above information and hereby give my permission**

PALM BEACH PEDIATRIC HEMATOLOGY ONCOLOGY

I (We) (Please, input Name below) authorize Melissa S. Singer, M.D., P.A. dba Palm Beach Pediatric Hematology Oncology and its personnel to deliver medical services to my child,

CHILD’S NAME

DATE OF BIRTH:

I (We) authorize the following people to bring my child in for treatment:

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Okay to leave a message on Voice mail

don’t Want Voice Mails For Results

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 Parent/Legal Guardian

Date:

Printed Name of Parent/Legal Guardian

Written Acknowledgements

Please initial each statement and sign below.

INDIVIDUAL’S FINANCIAL RESPONSIBILITY

A. I understand that I am financially responsible for my (child’s) health insurance deductible, coinsurance or non-covered services. Payments must be made within 30 days of receipt of the billing statement. Failure to make payments may result in delay of my (child’s) treatment or follow-up appointment.

B. Co-payments are due at the time of service.

If my (child’s) health insurance requires a referral from the primary pediatrician, I must obtain it prior to the visit.

C. In the event that my (child’s) health insurance plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the costs of all services provided within 30 days of the billing statement.

D. If I (my child) is uninsured, I agree to pay for the medical services rendered to me at the time of the service.

INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS

I hereby authorize and direct payment of my (child’s) medical benefits to Palm Beach Pediatric Hematology Oncology on my (child’s) behalf for any services furnished to me by the providers.

APPOINTMENT CANCELLATION PROCEDURE

I agree to call 24 hours prior to my scheduled appointment to cancel an appointment for myself (my child).

RECEIPT OF NOTICE OF PRIVACY PRACTICES: I have received a copy of the Notice of Privacy Practices from Melissa S. Singer, M.D., P.A. dba Palm Beach Pediatric Hematology Oncology

EMAIL CONSENT: By signing below, you acknowledge your recognition and understanding of the inherent risks of communicating your health information via email and hereby consent to receive such communications despite those risks. You agree to hold PBPHO harmless for unauthorized use, disclosure, or access of your protected health information sent to the email address you provide.

APRN: Please acknowledge that you have been informed of the Advance Practice Registered Nurse and their role at Palm Beach Pediatric Hematology Oncology.

As an Advance Practice Registered Nurse, her practice includes, but is not limited to, assessment; ordering, performing, supervising and interpreting diagnostic and laboratory tests; making diagnoses; initiating and managing treatment including prescribing medication and non-pharmacologic treatments; coordinating care; counseling; and educating patients and their parents and/or authorized representatives.

Patient Name:

Patient DOB:

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 Parent/Legal Guardian/Patient

Printed name of Parent/Legal Guardian/Patient

Relationship to Patient

Date:

Your information will be encrypted.