New Patient Form

Responsible Party

Primary Insurance Information

Secondary Insurance Information

Emergency Contact Information

I hereby assign my insurance benefits to be made directly to my physician and any assisting physicians, for services rendered. I hereby attest that the above insurance information is accurate and that I am an eligible member and understand that I am responsible for knowing my benefits/coverage. I will be financially responsible for all charges that are not covered by my insurance company. I understand that I will be charged a 1% finance charge on all accounts over 90 days. I also hereby authorize the release of all information to other physicians and insurance carriers upon request for the purpose of payment for medical services and further treatment of care by another physician. I further agree that a photocopy of this agreement shall be as valid as the original. Payment is due at the time services are rendered. All charges are the direct responsibility of the patient. We cannot render services on the assumption that our charges will be paid by the Insurance company. Insurance is an agreement between you and your insurance company. If we have problems collecting payment from you, we will also add attorney’s fees, collection agency costs and any related fees to your bill. A holder of this medical debt contract is prohibited by Section 1785.27 of the Civil Code from furnishing any information related to this debt to a consumer credit reporting agency. In addition to any other penalties allowed by law, if a person knowingly violates that section by furnishing information regarding this debt to a consumer credit reporting agency, the debt shall be void and unenforceable. I hereby acknowledge that I have read, understand, and agree to hereby give consent for treatment.

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.

Send Non-Urgent Messages and Pay Your Bills Online

Want to send Non-Urgent Messages or Request Medication Refills for your child? Like to pay your bills online? Rather not wait in line or on-hold? If"Yes" , please provide the following information, so you can

send non-urgent messages, request medication refills and view/pay your bills online. Please note: We are unable to make appointments online. Please print clearly (helps us with accuracy).

Communicating and Privacy Practices

Communicating with You

To effectively communicate with you about your medical and financial needs, we request that you complete this form identifying the best ways to provide you with your confidential information. We may need to communicate test results, prescription information, financial information or respond to a message you left for your physician’s office. We may communicate with you through mail, secure email (Secure Patient Portal), and telephone, including text messages, leaving messages on your answering machine’s/voice mail.

Please check all boxes that give Pediatric and Adolescent Medicine permission to use for your communications:

Please list any persons you would like to have access to your billing, appointment, or health information, such as your spouse, caretaker, or other family member. We will ask for additional consent prior to releasing information related to psychiatric services and/or HIV test results.

This request supersedes any prior request for communication of information I may have made.

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov

Acknowledgement of Receipt of Notice of Privacy Practices

I hereby acknowledge that I received a copy of the notice of Privacy Practices for the above medical practice. I further acknowledge that a copy of the current notice is posted in the reception area and that any amended notice of Privacy Practices will be made available at my next appointment.

If not signed by the patient, please indicate:

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.

General Fees for Pediatric and Adolescent Medicine

(Revised 04.18.2024)

1. We collect copayments and balances due for all visits when you check in, and this is based on the contractual agreement between you and your insurance health plan. We accept cash, checks, Visa, MasterCard and Discover Card.
2. When appointments are missed, or cancelled with little notice, it leaves an opening that could have been used for another patient. We reserve the option to charge $30.00 (or the amount of your copay) for NO-SHOWS for all types of visits. This fee is not covered by your insurance.
3. Document fees are assessed as follows:
   • $50.00 Document fee for all documents with the exception of FMLA Forms.
   • $70.00 FMLA Form Fee.
   • Document Fees are included in the Annual Administration Fee for all patients enrolled.
4. We charge for the following services that are not covered by your insurance:
   • Repeated requests for transfer of medical records from doctor to doctor as well as copies of records sent to parent(s) for personal use-$30.00 flat rate for a multi-page PDF, CDR. Paper copies can be requested for an additional $0.25 per page.
   • Returned check charge-$30 per check.

If you have any questions about our fees or payment policies, please feel free to speak with our Office Manager.

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.

Vaccine Information We are a vaccinating office.

I have received the US Department of Health and Human Service vaccine handouts. I understand and agree:

1. With all vaccinations, there are certain benefits and risks and that these handouts help identify them.
2. To read these handouts in detail and bring up any risk factors identified in them to the physician.
3. To address any questions or concerns regarding the accompanying information prior to receiving the immunizations and allow the physician an opportunity to address any concerns.
4. That the physician will fully explain any unclear portions of the immunization handouts and answer any questions that I raise.
5. Not to discard these handouts and to review them prior to the routine immunizations as outlined in the enclosed schedule and again raise any new or old questions or concerns.
6. Unless otherwise stated prior to these immunizations being given, to understand the benefit and risks to the routine childhood immunizations and to have the physician administer these same immunizations as he/she feels are clinically indicated.

Eligibility Guarantee Form

(revised 01.01.2020)

1. Assign my insurance benefits to be made directly to my (child’s) physician and/or assisting physicians.

2. Agree that if I change my child’s insurance coverage it is my responsibility to notify the office.

3. Attest that the insurance information provided is accurate and that my child is an eligible member. I understand that if my child is not eligible for health care benefits then I am responsible for all charges.

4. Will be financially responsible for all charges that are not covered by my insurance company, for services rendered in the office, or referrals to another physician/facility.

5. Understand that if a referral to another physician or facility is necessary, and our insurance requires specific physicians or facilities be utilized, and/or there are specific requirements regarding their notification or authorization, it is my responsibility to notify the office so they can make the appropriate choice and verify.

6. Authorize the release of all information to other physicians and insurance carriers upon request for the purpose of payment and/or further treatment.

7. Agree that a photocopy of this agreement shall be as valid as the original.

8. Agree payment is due at the time services are rendered. If there are problems collecting payments, attorney’s fees, collection agency costs and any related fees will be my responsibility.

9. A holder of this medical debt contract is prohibited by Section 1785.27 of the Civil Code, from furnishing any information related to this debt to a consumer credit reporting agency. In addition to any other penalties allowed by law, if a person knowingly violates that section by furnishing information regarding this debt to a consumer credit reporting agency, the debt shall be void and unenforceable.

10. Am responsible for knowing and understanding my (child’s) benefits/coverage. I understand that services cannot be rendered on the assumption that charges will be paid by the insurance company and that coverage is an agreement between me and my child’s insurance company.

12. Acknowledge that I have read, understand and agree to hereby give consent to assess, treat and test my child.

AUTHORIZATION TO CONSENT TO TREATMENT OF MINOR

I have read and understand the above information. I have been informed of my responsibilities and I understand them fully.
This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.
This authorization shall remain effective until 1 January, 2030, unless sooner revoked in writing and delivered to said agent.