Patient Information Packet

PEDIATRIC HEALTHCARE ASSOCIATES, PA

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Patient Information

Parent or Guardian Information

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INSURANCE INFORMATION

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.

BIRTH HISTORY

GENERAL

DEVELOPMENT

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Health History

Condition


Patient


Family History

Communication Consent

Your physician(s) and other staff members will, at times, need to contact you. By filling out the information below, we will be better able to serve you.

By checking one of the boxes for Preferred Communication Method, I agree to receiving correspondence from Pediatric Healthcare Associates, PA

UNLESS WE HAVE YOUR WRITTEN PERMISSION TO DO SO, WE WILL NOT LEAVE MESSAGES WITH ANYONE EXCEPT THE PATIENT, PARENT OR LEGAL GUARDIAN.

I agree to the above medical release. I understand that this agreement will be in effect until I revoke it in writing.

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.

Consent & Authorizations for Services

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.

Financial Policy

Cancellation and No Show Policy

By signing this form, I agree to the above financial policies and understand the cancellation and No Show policies and fees.

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.

Notice of Privacy Practices Acknowledgement

  • Conduct, plan, and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in the treatment directly and indirectly.
  • Obtain payment from third party payors.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.

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.

Vaccination Policy

As of October 1, 2015, Pediatric Healthcare Associates, PA, no longer accepts NEW patients that do not adhere to the standard immunization schedule based on the recommendations of CDC (Centers for Disease Control) and AAP (American Academy of Pediatrics). Exceptions to this policy should be discussed with your child’s provider regarding any deferment or delay in the vaccination schedule.

CDC and AAP recommended Immunization Schedule example:

Patient Age

2 months
4 months
6 months
12 months
15 months
18 months
4-6 years
11-12(or later)
16 years

Immunizations

Rotavirus, DTaP, Hib, PCV20, IPV, Hep B2 months
Rotavirus, DTaP, Hib, PCV20, IPV, Heb B
Rotavirus, DTaP, Hib, PCV20, IPV, Heb B
PCV20, MMR, Varicella, Hep A
DTaP, Hib
Hep A
Dtap, IPV, MMR, Varicella
TDaP, Meningococcal
HPV#1,2,3
Meningococcal

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.

Authorization for Medical Care to Minors

do hereby authorize the below individual(s) to consent to medical treatment of my child, in my absence at Pediatric Healthcare Associates, P.A..

Name of the adult person(s) authorized to bring minor child in for medical treatment.

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I agree that the above authorization for medical care to my minor child will be in effect until I revoke it in writing.

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.

Forensic Services Agreement

This Forensic Services Agreement (the “Agreement”) must be signed by any patient or guardian of a patient (“you”) before you can become eligible to receive treatment or services from Pediatric Healthcare Associates.

Pediatric Healthcare Associates only provides in-office pediatric medical services to patients seeking treatment. Pediatric Healthcare Associates reserves the right, in Pediatric Healthcare Associates’ sole discretion, to decline to provide any services to client in any fashion or venue apart from a regularly scheduled in-office visit.

Pediatric Healthcare Associates does NOT provide forensic legal services to any parties, NOR does Pediatric Healthcare Associates desire to provide such services for clients, their families, or their adverse or potentially adverse parties.

Pediatric Healthcare Associates does NOT conduct forensic custody evaluations, social studies, or other forensic evaluations for patients for use in legal proceedings, whether in court or out of court.

Pediatric Healthcare Associates ONLY provides pediatric medical treatment to patients who seek to improve their health or to identify and treat medical issues. Pediatric Healthcare Associates will not, under any circumstances, begin providing treatment to your child and later assume an engagement for forensic services, whether intentionally or unintentionally.

Pediatric Healthcare Associates understands, however, that your life circumstances may change, and you may (or a court or another party involved in litigation with or against you may) compel or otherwise seek to have Pediatric Healthcare Associates personnel appear for a deposition, court testimony, or appear for some other legal proceeding. PEDIATRIC HEALTHCARE ASSOCIATES CANNOT CHARGE YOUR INSURANCE FOR THESE PURPOSES AND SERVICES. Due to insurance reimbursement restrictions, to the extent you (or any other party involved in litigation with or against you) wish to secure Pediatric Healthcare Associates’ services for any reason (other than for an in-office visit for pediatric medical treatment), including services or appearances in anticipation of a lawsuit or after the commencement of a lawsuit or any and all matters compelled by lawful subpoena or court order pertaining to client matters (collectively referred to hereafter as “Forensic Services”), you must pay, in full and in advance, for such requested services according to the terms of this Agreement. To the extent any such Forensic Services are reimbursed or covered by your insurance, it is your sole responsibility to file any required or necessary paperwork to recover any fees charged by Pediatric Healthcare Associates for Forensic Services.

Your Payment Obligation to Pediatric Healthcare Associates in the event Forensic Services are requested by parent/patient/legal guardian are as follows:

  • Pediatric Healthcare Associates requires payment upfront for a minimum three-hour time commitment by Pediatric Healthcare Associates for any Forensic Services. You must pay Pediatric Healthcare Associates a minimum, non-refundable, three- hour retainer ($900 or $1,200 as outlined above) prior to Pediatric Healthcare Associates’ preparation or travel for the provision of Forensic Services.
  • Pediatric Healthcare Associates will charge you in quarter-hour (15 minute) increments for Forensic Services.
  • Pediatric Healthcare Associates will charge you for any travel time and waiting time incurred by Pediatric Healthcare Associates in the course of provision of these Forensic Services, in addition to any time actually spent providing Forensic Services.
  • Pediatric Healthcare Associates will charge you the full costs associated with any travel for the provision of Forensic Services, in addition to fees for Pediatric Healthcare Associates’ time in the provision of Forensic Services (as outlined above). You will be responsible for paying 100% of all travel costs incurred by Pediatric Healthcare Associates.

Further, to the extent possible, you also agree to give the nurse, staff member, or licensed physician twenty-one (21) days’ advanced notice of your need for Forensic Services from Pediatric Healthcare Associates, another party’s or court’s need for Forensic Services from Pediatric Healthcare Associates, or any event requiring our attendance.

Client understands, agrees, and consents that Pediatric Healthcare Associates may disclose client’s confidential information or Protected Health Information (“PHI”) in the possession of Pediatric Healthcare Associates as reasonably necessary to comply with the requirements of any lawful subpoena or court order.

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.

Texas Immunization Registry (ImmTrac2)

Minor Conset Form

A parent, legal guardian or managing conservator must sign this form if the client is younger than 18 years of age.

The Texas Immunization Registry (ImmTrac2) is a free service of the Texas Department of State Health Services (DSHS). The Texas Immunization Registry is a secure and confidential service that consolidates and stores your child’s (younger than 18 years of age) immunization records. With your consent, your child’s immunization information will be included in the Texas Immunization Registry. Doctors, public health departments, schools, and other authorized professionals can access your child’s immunization history to ensure that important vaccines are not missed. For more information, see Texas Health and Safety Code Sec. 161.007 (d). https://statutes.capitol.texas.gov/Docs/HS/htm/HS.161.htm#161.007.

Consent for Registration of Child and Release of Immunization Records to Authorized Persons/Entities

I understand that, by granting the consent below, I am authorizing release of the child’s immunization information to DSHS and I further understand that DSHS will include this information in the Texas Immunization Registry. Once in the Texas Immunization Registry, the child’s immunization information may by law be accessed by a public health district or local health department, for public health purposes within their areas of jurisdiction; a physician, or other health-care provider legally authorized to administer vaccines, for treating the child as a patient; a state agency having legal custody of the child; a Texas school or child-care facility in which the child is enrolled; and a payor, currently authorized by the Texas Department of Insurance to operate in Texas, regarding coverage for the child. I understand that I may withdraw this consent at any time by submitting a completed Withdrawal of Consent Form in writing to the Texas Department of State Health Services, Texas Immunization Registry

State law permits the inclusion of immunization records for First Responders and their immediate family members in the Texas Immunization Registry. A “First Responder” is defined as a public safety employee or volunteer whose duties include responding rapidly to an emergency. An “immediate family member” is defined as a parent, spouse, child, or sibling who resides in the same household as the First Responder. For more information, see Texas Health and Safety Code Sec. 161.00705. https://statutes.capitol.texas.gov/Docs/HS/htm/HS.161.htm#161.00705. Please mark the box below to indicate whether your child is an Immediate Family Member of a First Responder. I am an IMMEDIATE FAMILY MEMBER of a First Responder.Formatted text

By my signature below, I GRANT consent for registration. I wish to INCLUDE my child’s information in the Texas Immunization Registry

Parent, legal guardian, or managing conservator:

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.

Privacy Notification: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.texas.gov for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)

PROVIDERS REGISTERED WITH the Texas Immunization Registry: Please enter client information in the Texas Immunization Registry and affirm that consent has been granted. DO NOTfax to the TexasImmunization Registry. Retain this form in your client’s record.

Authorization to Release Confidential Medical Information

medical records be released to:

Pediatric Healthcare Associates, P.A.
3701 Eldorado Parkway, Ste. A McKinney, TX 75070
Phone: 972-548-7888 Fax: 972-562-1170

My records are being transferred from:

As the guardian of the patient named below, I give permission to release all medical, mental, and social information to the facility listed. All medical records, meaning every page in my record, including but not limited to: office notes, face sheets, history and physical, consultation notes, inpatient, outpatient and emergency room treatment, all clinical charts, reports, order sheets, progress notes, nurse's notes, social worker records, clinic records, treatment plans, admission records, discharge summaries, requests for and reports of consultations, documents, correspondence, test results, statements, questionnaires/histories, correspondence, telephone messages, and records received by other medical providers. All laboratory records, radiology and diagnostic reports. I understand that this information is confidential and will only be used for the benefit of the patient. I further understand that this release is valid for one year or until I revoke the authorization in writing.

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.

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