Patient Forms (English)

Please correct the errors described below.

PEDIATRIC HISTORY

Birth History:

Hospitalizations / Operations of child:

Add new row

Immunizations

Social and Environmental History:

Medical History:

Family History:

Please check all that apply:

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.

PATIENT REGISTRATION

CHILD'S INFORMATION

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

MOTHER OR GUARDIAN INFORMATION

FATHER OR GUARDIAN INFORMATION

INSURANCE INFORMATION - Primary coverage:

INSURANCE INFORMATION - Secondary coverage:

IN CASE OF EMERGENCY CONTACT:

Add new row

LIST BROTHERS/SISTERS WHO ARE PATIENTS HERE:

Add new row

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.

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.

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

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.

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.

(Printed Name - Patient or Representative)
(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.

Your message will be encrypted.