PEDIATRICS FORM

CHILD

Last Name:

First Name:

MI:

Address:

City:

State:

Zip:

Soc Sec Number:

Date of Birth:

Sex:

Telephone Number:

Email:

FATHER

Last Name:

First Name:

Address:

City:

State:

Zip:

Soc Sec Number:

Date of Birth:

Employer:

Work Number:

EMERGENCY CONTACT: (Other than parent)

Name:

Relationship to Child:

Telephone:

Address:

City:

State:

Zip:

RESPONSIBLE PARTY:

Name:

Relationship to Child:

INSURANCE:

1st Company Name:

ID #:

Group #:

Policy Holder:

Relationship to Child:

2nd Company Name:

ID #:

Group #:

Policy Holder:

Relationship to Child:

BENEFITS AUTHORIZATION:

I authorize treatment of the patient named above and agree to pay all fees and charges billed by Progressive Physicians Practice. I request that payment of authorized Insurance Company or third party insurance be made to Progressive Physicians Practice or one of its physicians if assignment is accepted in which case agree to pay any deductible, co-payment or disallowed charges. If assignment is not accepted I agree to pay the entire amount due. I authorized any holder of medical information about me to be released to the Health Care Financing Administration and its agents, the Division of Medicaid and their Fiscal Agent or any third party insurance, any information needed to determine these benefits. If you default on any payment you will be responsible for any COLLECTION AGENCY CHARGES.

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.

Parent or Guardian Signature:

Date:

Initial History Questionnaire

Forms Completed By:

Date Completed:

Name:

ID Number:

Birth Date:

Age:

Household:

Please list all those living in the child's home.

Name

Relationship to child

Birth Date:

Health Problems:

Are there siblings not listed? If so, please list their names and ages and where they live.

If mother and father are not living together or if child does not live with parents, what is the child's custody status?

If one or both parents are not living in the home, how often does he/she see the parent/parents not in the home?

Birth History

Birth Weight:

Was the baby born at term?

Early?

Late?

If early How many weeks' gestation?

Did mother have any illness or problem with hr pregnancy?

Yes No

Explain

During pregnancy, did mother

Smoke

Yes No

Drink Alcohol

Yes No

Use drugs or medications

Yes No

What

When

Was the delivery

Vaginal Cesarean

If cesarean, why?

Did your baby have any problems right after birth?

Yes No

If cesarean, why?

Was initial feeding

Breast Bottle

Did your baby go home with mother from the hospital?

Yes No

Explain

General

Do you consider your child to be in good health?

Yes No

Explain

Does your child have any serious illness or medical condition?

Yes No

Explain

Has your child had serious injuries or accidents?

Yes No

Explain

Has your child have any surgery?

Yes No

Explain

Has your child ever been hospitalized?

Yes No

Explain

Is your child allergic to any medicines or drugs?

Yes No

Explain

Development

Are you concerned about your child's physical development?

Yes No

Explain

Are you concerned about your child's mental or emotional development?

Yes No

Explain

Are you concerned about your child's attention span?

Yes No

Explain

If your child is in school:

How is his/her behavior in school?

Has he/she failed or repeated a grade in school?

How is he/she doing in academic subjects?

Is he/she in special or resource classes?

Family History

Have any family members had the following:

Who

Comments

Who

Comments

Who

Comments

Who

Comments

Who

Comments

Who

Comments

Who

Comments

Who

Comments

Who

Comments

Who

Comments

Who

Comments

Who

Comments

Who

Comments

Who

Comments

Who

Comments

Who

Comments

Who

Comments

Who

Comments

Who

Comments

Additional Family History

Past History

Does your child have, or has he/she ever had:

When

Explain

When

Explain

PROGRESSIVE PHYSICIAN PRACTICE, PLLC

CERTIFIED PEDIATRICIAN

DR. REMI ADESOJI

This form is to give us permission to see your child when brought in by other family members or friends. Please list the persons that you give permission to bring your Child/children to the physician.

Name / Relationship:

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.

Parents Signature:

TO: Patient with Medicaid Coverage

(Name of the patient guardian)

Certify that

(Name of the patient)

Has no other medical insurance coverage including Commercial, Blue Cross/Blue Shield or other insurance plans.

Signed

Date

RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGMENT OF RECEIPT

I (Please input Name below) have received a copy of Progressive Physicians Practice’s notice ofPrivacy Practices and I have been given an opportunity to ask questions.

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 Patient/ Parent

Date

FINANCIAL AGREEMENT

The undersigned severally agrees, whether signing as a patient or otherwise, that in consideration of the services rendered to the patient, payment of the account is guaranteed by the undersigned. While any insurance or other protection related to the account may be hereby assigned to and payable directly to us, the undersigned clearly understands that the obligation to pay the bill is primarily on the patient and account, any part of the account not so paid by insurance is nevertheless owing and payable. In case of default of payment, and if this account should be placed in the hands of a collector or an attorney for collection, all collection fees, attorney fees, cost and other expenses will be paid by the undersigned.

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.

Parent's or guarantor's Signature

Guarantor's Signature

Date

AUTHORIZATION FOR DISCLOSER OF HEALTH INFORMATION

Patient Name:

Date of Birth:

Phone:

Address:

City:

State:

Zip:

1. I authorize the use or disclosure of the above named individual's health information as described below.

2. The following individual or organization is authorized to make this discloser:

Name of Hospital, Clinic, and/or Facility:

Address:

City:

State:

Zip:

Phone:

Fax:

3. The type and amount of information to be used or disclosed is as follows: (Includes dates where appropriate.)

Compare health records

Lab results/ X-ray reports

Physical exam

Consultation reports

Immunization records

Other (Please specify)

4. I understand that the information in my health record may include information relating to sexual transmitted disease, acquired immunodeficiency syndrome (AIDS) or human Immunodeficiciency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.

5. This information may be disclosed to and used by the following individual or organization

PROGRESSIVE PHYSICIANS PRACTICE, PLLC8412 AIRWAYS BLVD SOUTHAVEN, MS

38671662-536-2100 PHONE | 662-536-2211 FAX

6. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the Health Information Management department at PROGRESSIVE PHYSICIANS PRACTICE 8412 AIRWAYS BLVD, SOUTHAVEN MS. 38671. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy, unless otherwise revoked; this authorization will expire in 60 days.

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.

PATIENT SIGNATURE(OR LEGAL REPRESENTATIVE)

Date

Your information will be encrypted.