Patient Forms (English)

PEDIATRIC HISTORY

Name:

Date of Birth:

Sex:

Female Male

Birth History:

Where there any problems with pregnancy or delivery of this child?

Yes No

If yes, please explain:

Term?

Premature?

Type of Delivery

Vaginal C-section

Birth Length:

Birth Weight:

Problems:

Jaundice

Respiratory Distress

Feeding Problems

Rash

Breech

Hospitalizations / Operations of child:

Hospital:

Reason:

Year:

Hospital:

Reason:

Year:

Hospital:

Reason:

Year:

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Current Medications and Dosages:

Yes None

If yes, please list:

Allergies to any medication?

Yes None known

If yes, please list:

Immunizations

Are your child's immunizations up to date?

Yes No Unsure

Social and Environmental History:

Who does the child live with?

Is the home tobacco free:

Yes No

Are there smoke detectors in the home?

Yes No

Do you use your seat belts/car seats?

Yes No

Is your child in school or day care?

Yes No

Does your child wear a bike helmet while riding?

Yes No

Are there guns in your home?

Yes No

Do you have the poison-control center phone number near your telephone?

Yes No

Medical History:

If Other is selected, please explain:

Family History:

Please check all that apply:

For Cancer, please specify what type:

For Diabetes, please select:

1 2

(For Other, please specify:)

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.

Parent/Guardian Name:

Date:

PATIENT REGISTRATION

Location:

Preston Broadway

Physician: (patient normally sees):

Date:

Ethnicity:

Hispanic/non Latino Hispanic/Latino Unknown Declined Other

If Other, please specify:

CHILD'S INFORMATION

Last name:

First name:

M.I.:

Address:

Apt. #:

City:

State:

Zip Code:

Home phone:

Sex:

Female Male

SS#:

Race:

Date of Birth:

Primary language spoken:

Medical alert:

Persons listed In this section have authorization to consult and discuss patients treatment and billing infonnation.

MOTHER OR GUARDIAN INFORMATION

Patient lives with:

Both parents Mom Dad Guardian

Last name:

First name:

M.I.:

Address:

City:

State:

Zip Code:

Home phone:

Work phone:

Cell:

Date of Birth:

SS#:

Language:

Email Address:

Employer:

Employer phone:

FATHER OR GUARDIAN INFORMATION

Patient lives with:

Both parents Mom Dad Guardian

Last name:

First name:

M.I.:

Address:

City:

State:

Zip Code:

Home phone:

Work phone:

Cell:

Date of Birth:

SS#:

Language:

Email Address:

Employer:

Employer phone:

Preferred pharmacy and location:

INSURANCE INFORMATION - Primary coverage:

Insurance Co.:

Address:

Policy#:

Group#:

Effective date:

Pt's relationship to insured:

Insured's name:

Insured's address:

Insured's phone:

Insured's date of birth:

Insured's employer:

Employer's address:

INSURANCE INFORMATION - Secondary coverage:

Insurance Co.:

Address:

Policy#:

Group#:

Effective date:

Pt's relationship to insured:

Insured's name:

Insured's address:

Insured's phone:

Insured's date of birth:

Insured's employer:

Employer's address:

IN CASE OF EMERGENCY CONTACT:

Name of person NOT living with patient:

Relationship to patient:

Home phone:

Work phone:

NAME OF OTHER PHYSICIAN(S) WHO CARE FOR PATIENT:

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LIST BROTHERS/SISTERS WHO ARE PATIENTS HERE:

Last name:

First name:

DOB:

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NO SHOW APPOINTMENTS

I understand that it is my responsibility to notify, 24 hours in advance, Pediatric & Neonatal Specialists, PSC in the event that I must cancel an appointment. I am fully responsible for the charge of $20.00 which will be applied to my account for appointments that are missed without notifying the office.

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.

Authorized person's name:

Date:

CONSENT TO TREAT/INFORMATION RELEASE

(print name)

hereby consent to the use and disclosure of my child's health information for the purposes of treatment, payment and health care operations. I authorize the physicians/nurse practitioners to render medical treatment as needed for my child. I also request payment be made to Pediatric & Neonatal Specialists, PSC. The undersigned is responsible for all fees, regardless of Insurance coverage. A copy of this authorization is as valid as the original.

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.

Authorized person's name:

Date:

Persons listed in this section have authorization to consult and discuss patients treatment and billing information.

I authorize

to accompany my child to your office for treatment by your physicians/nurse practitioners.

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.

Authorized person's name:

Date:

HOW DID YOU HEAR ABOUT THIS PRACTICE?

Referral by another patient/relative?

Referral by another physician?

Insurance plan/provider?

Physician Referral Service/Hospital?

Advertisement?

Yellow Pages?

Internet?

REASONS WHY YOU SELECTED THIS PRACTICE

Convenient location?

Type of service available?

Other

If Other is selected, please specify

Name of person who referred patient to this office:

PATIENT CONSENT FORM

Pediatric & Neonatal Specialists, PSC's Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but If we do, we shall honor that agreement.

By signing this form, you consent to our use and, disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The patient understands that:

Protected health information may be disclosed or used for treatment, payment or health care operations.
The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
The Practice reserves the right to change the Notice of Privacy Policies.
The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions.
The patient may revoke this Consent in writing at any time and all future disclosures will then cease.

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.

This Consent was signed by:

(Printed Name - Patient or Representative)

Relationship to Patient (if other than patient):

Date:

In front of

(Printed name - Practice representative)

FINANCIAL POLICIES

Thank you for choosing Pediatric & Neonatal Specialists to care for your child(ren). The following information is provided as a guide to understanding our financial requirements. Should you have any questions please call our Billing Department at (502) 893-5502, Monday through Friday, 8:00 a.m. to 4:30 p.m.

Patients with insurance will be asked to provide Insurance card(s) at every visit. We accept most insurance. If insurance coverage should change please notify the receptionist at the next office visit and
provide us with the new insurance card(s). If there is more than one insurance carrier (one insurance is primary and the other is secondary), you must provide the insurance cards for both. Be advised that your primary insurance will not pay any claims without first receiving information from you on your secondary insurance.

The parent/legal guardian is responsible for all fees whether or not the insurance company pays. As a courtesy for our patients we will file a claim to the insurance company for services provided. Any fees not paid by the insurance company will be billed to the parent/legal guardian and immediate payment is expected. We do not act as an intermediary between the insured and the insurance company. Please contact the customer service representative of the insurance company if you are dissatisfied with the result of a claim and feel a service should be covered.

There is a $20 charge for no shows. Notify us 24 hours in advance to cancel or reschedule the appointment to avoid this fee.

Read your insurance policy so you are informed about what is covered. It is the parent/legal guardian's responsibility to ensure we are an in-network provider, to know what services are covered and co-pay requirements. Please note certain immunizations are not covered by most insurance and the patient may have a co-pay amount that is different from the office visit co-payor there may be no co-pay required.

We send statements monthly. Balances due from the responsible party that are two (2) months old will be placed in collection. The responsible party will have seven (7) days from the date we send a collection letter to pay the balance. Balances that remain unpaid atter collection will be turned over to an outside agency and the patient will be discharged. The parent/legal guardian agrees to pay all costs of collection, including reasonable legal fees.

Self pay (patients without insurance coverage or where insurance coverage cannot be verified) are expected to pay their bill in full at the time of service unless prior arrangements have been made with the Billing Department.

I have read, understand and agree to these financial policies.

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.

Name of Parent/Legal Guardian:

Date:

Your information will be encrypted.