NEW PATIENT FORMS

PATIENT INFORMATION

DATE OF FIRST VISIT:

PATIENT'S FULL NAME:

LAST:

FIRST

MIDDLE:

NICKNAME OR CALL NAME:

HOME ADDRESS:

STREET:

CITY:

STATE:

ZIP CODE:

HOME TELEPHONE:

DATE OF BIRTH:

SEX:

MALE FEMALE

SOCIAL SECURITY NUMBER:

INSURANCE DATA

SUBSCRIBER/INSURED:

INSURANCE CO.:

CONTRACT OR I.D. NUMBER:

GROUP NUMBER:

EFFECTIVE DATE:

DOCTOR:

FAMILY DATA

MOTHER:

NAME:

DATE OF BIRTH:

ADDRESS:

CITY:

STATE:

ZIP CODE:

EMPLOYER:

POSITION HELD:

WORK PHONE #:

HOME PHONE #:

CELL PHONE #:

SOCIAL SECURITY NUMBER:

FATHER:

NAME:

DATE OF BIRTH:

ADDRESS:

CITY:

STATE:

ZIP CODE:

EMPLOYER:

POSITION HELD:

WORK PHONE #:

HOME PHONE #:

CELL PHONE #:

SOCIAL SECURITY NUMBER:

ADDITIONAL INFORMATION

REFERRED BY:

FRIEND OR FAMILY MEMBER FOR EMERGENCIES:

Emergency Contact Phone Number

LIST ALL CHILDREN IN FAMILY LESS THAN 18 YEARS OLD

NAME:

SEX:

MALE FEMALE

BIRTHDAY:

REMARKS:

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PEDIATRIC HEALTH HISTORY FORM - INITIAL VISIT

Child's Name:

Date of Birth:

Age:

Your Name:

Relationship to Child:

CHILD'S PAST MEDICAL HISTORY

Pregnancy/Neonatal Period

Where was your child born?

Is the child yours by

Birth Adoption Stepchild Other

Pregnancy complications:

Delivery by:

Vaginal C-section

Reason for C-section:

Complications:

Was your child premature

No Yes

born at

Complications:

Apgar scores:

1 minute:

5 minutes:

Birth weight:

Length:

SOCIAL HISTORY

Who lives in the household with the child?

Mom Dad Siblings Grandparents Other

If Siblings is selected, please specify the number:

If Other is selected, please specify:

Child's parents are

Married Unmarried Divorced Other

If Other, please specify:

Childcare

Parents Relatives Daycare Babysitter/Nanny

Days per week in childcare (not with parents):

Do any household members smoke?

Yes No

How many hours per day does your child spend:

Watching TV:

Computer:

Video games:

Child's school name:

Grade:

Any concerns about school performance?

Yes No

If yes, please explain:

Any concerns about peer or teacher relationships?

Yes No

If yes, please explain:

Sports/exercise: Type

How often?

How long

FAMILY HISTORY

Do any family members have any of the following conditions:

Please explain all positives:

REVIEW OF SYSTEMS (Please select all that apply)

Constitutional

Fever, chills

Fatigue

Unexplained weight loss/gain

Excessive thirst

Ear, Nose, and Throat

Loud voice, hearing problem

Mouth-breathing, snoring

Ear pain

Frequent runny nose

Respiratory

Cough, short of breath

Chest tightness, wheeze

Musculoskeletal

Muscle pain, weakness

Joint pain, swelling

Bone pain

Gastrointestinal

Nausea, vomiting, diarrhea

Constipation, blood in stool

Abdominal pain

Cardiovascular

Chest pain, palpitations

Tires easily with exertion

Fainting

Genitourinary

Frequent or painful urination

Bedwetting, frequent accidents

Vaginal or penile discharge

Neurologic

Headaches

Clumsiness

Seizures

Milestone delay

Reviewed by:

Date:

Patient's Name:

First:

MI:

Last:

Date of Birth:

Social Security Number:

Patient Resides With:

Both Parents Mother Father Other

If other, please specify:

Insurance Company:

Subscriber:

Contract No.:

Group No.:

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PARENTS' / GUARDIANS' NAMES AND ADDRESS(ES)

Mother:

Name:

Street Address:

City:

State:

Zip:

Home #:

Please select:

Cell phone

If Cell Phone is selected, please input Cell #:

Please specify Cell Service:

AT &T

Boost

Nextel

Sprint

Straight Talk

T-Mobile

Verizon

Other

If other, please specify:

If Email is selected, please input email address:

Place of Employment:

Work #:

Father:

Name:

Street Address:

City:

State:

Zip:

Home #:

Please select:

Cell Phone

If Cell Phone is selected, please input Cell #:

Please specify Cell Service:

AT &T

Boost

Nextel

Sprint

Straight Talk

T-Mobile

Verizon

Other

If other, please specify:

If Email is selected, please input email address:

Place of Employment:

Work #:

By signing below, I agree to receive notification from Redmont Pediatrics regarding my child's health care via texts and/or emails. I have indicated with an "X" preceding the Cell #(s) or Email(s) to indicte the methodes) I prefer to receive these notices. I can select more than one option.

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.

Mother:

Father:

If Patient is over 14 Years Old, please input Patient's Cell #:

I have reviewed the information listed above and it is correct.

Date:

Initial:

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FINANCIAL RESPONSIBILITY

I hereby assign to Redmont Pediatric Associates, P .C. all payments for medical services rendered. I acknowledge full financial responsibility for all services provided, both those covered by my insurance contract and those non-covered services that may be deemed necessary for appropriate medical care. I accept full responsibility for knowing my insurance benefits and will advise the staff of Redmont Pediatrics accordingly. I understand that charges incurred are due at the time of service unless other financial arrangements have been made prior to treatment.

I also understand that charges may be incurred for other services provided, including a $20.00 cancellation fee when a well check-up is cancelled less than 24 hours before the appointment, a $20.00 fee for checks returned for insufficient funds and a $5.00 administrative processing fee for completion of forms. I understand that I am responsible for any and all charges incurred and that if the account-remains unpaid and is referred to an attorney or collection agency, all costs of collections, including reasonable attorney's fees, will be my responsibility.

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/Guardian:

Patient's Name:

Date:

Father (Agreement to Pay):

Mother (Agreement to Pay):

Signature of Patient Age 14 -19 (Agreement to Pay):

The responsible party understands that no oral or written contract exists which designates by name or description the individual who will treat the patient.

I understand that any release of Infonnatioll or consent to treat other than the authorizations listed above will require my written or verbal approval.

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:

Date:

HIPAA NOTICE OF PRIVACY PRACTICES

I have received a copy of Redmont Pediatric Associates, P.C. Notice of Privacy Practices. I am aware that this office is HIP AA compliant and is following federally regulated guidelines regarding my protected health information.

*Name of Parent:

Date:

Signature of Patient (Age 14 - 19):

Date:

CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

You hereby consent for Redmont Pediatric Associates, P.C. to use or disclose information about you (or another person for whom you have the authority to sign) that is protected under federal law for the purposes of treatment, payment, and healthcare operations. Due to recent changes involving federal laws regarding your Privacy, our authorizations are more extensive than ever before. Please understand that the goal of Redmont Pediatrics is to administer the best medical care available in the most efficient manner. We will strive at all times, to the best of our ability, to protect your privacy.

Please understand that in the normal course of running our medical office, discussions can sometimes be overheard. Ask at any time if you would like to assure a totally confidential discussion with one of the doctors, lab technicians, nurses or business office staff members.

Please read carefully the authorizations below and sign appropriately.

I hereby authorize Redmont Pediatric Associates, P.C. to communicate confidential information to any referring or consulting physician, to any medical facility or to my insurance carrier by facsimile, electronic transmission, telephone or U.S. mail. My personal information is protected under federal law and I have the right to revoke this consent at any time. By signing below, I recognize that the protected health information used or disclosed may be subject to re-disclosure by the recipient and may no longer be protected under federal law.

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 Patient (If under age 14, must be signed by parent or guardian)

Date:

ADOLESCENT PATIENTS (Ages 14-19)

I hereby authorize the physicians of Redmont Pediatrics to discuss my medical condition and treatment plan with my parent or guardian. I understand that if financial responsibility is assumed by my parent or guardian, they will have the right to review services rendered. I may ask for a private consultation with my physician at any given time.

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 Patient Age 14 -19:

Date:

AUTHORIZATION TO PRESENT FOR MEDICAL TREATMENT

I hereby give my consent for medical treatment from the physicians of Redmont Pediatric Associates, P.C. I also authorize the following individuals to present with my child for medical treatment. In case of an emergency, I may be reached by telephone for verification if the person accompanying the patient is not named below.

Name:

Phone:

Relationship:

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*Name of Patient if 14 or Over / Parent:

Date:

NOTICE OF PRIVACY PRACTICES

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and our responsibilities to help you.

A) Get a copy of your paper or electronic medical record. You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy of a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee for this service.

B) Correct your paper or electronic medical. record. You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say "no" to your request, but we will tell you why in writing within 60 days.

C) Request confidential communications. You can ask us to contact you in a specific way (for example, home, office or cell phone) or to send mail to a different address. We 'will say "yes" to all reasonable requests.

D) Ask us to limit the information we use or share. You ca ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care. If you pay for a service of health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations 'with your health insurer. We will say "yes" unless a law requires us to share that information.

E) Get a list of those with whom we have shared your information. You can ask for a list (accounting) of the times we have shared your health information for six years prior to the date that you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting per year free of charge but 'will charge a reasonable, cost-based fee if you ask for another copy within 12 months.

F) Get a copy of this Privacy Notice. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

G) Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health care information. We will make sure the person has this authority and can act before we take any action.

H) File a complaint if you believe your privacy rights have been violated. You can file a complaint by text to redmontp@gmail.com, by sending a letter to the Privacy Officer, Beth Blair, at Redmont Pediatric Associates, P .C, 805 St. Vincent's Drive, Suite #430, Birmingham, Alabama 35205 or by calling (205) 939-1250. You can also complain to the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, SW, Washington, D.C. 20201, calling (877) 696-6775 or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. You have some choices in the way that we use and share information about your health care information. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do and we will follow your instructions.

A) Share information with your family, close friends or others involved in your care.

B) Share information in a disaster relief situation If you are not able to tell us your preference, for example, if you are unconscious, we may proceed and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

C) Marketing Purposes. We will never market or sell any personal information.

D) Share Specified Records. We will never share substance abuse records or mental health records without your written consent.

Our Uses and Disclosures

How do we typically use or share your health information? We may use and share your information as we:

A) Treat you. We can use your health information and share it with other professionals who are treating you.

B) Run our practice. We can use and share your health information to run our practice, improve you care and contact you when necessary.

C) Bill for your services. We can use and share your health information to bill and get payment from health plans or other entities including collection agencies if needed.

How else can we use or share your health information? We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hss.gov/ocr/privacy/hipaa/understanding/consumers/index.html

A) Help with public health and safety issues. We can share health information about you for certain situations such as preventing disease, helping with product recalls, reporting adverse reactions to medications, reporting suspected abuse, neglect or domestic 'violence and preventing or reducing a serious threat to anyone's health or safety.

B) Comply with the law. We will share information about you if a state or federal laws require it, including the Department of Health and Human Services is it wants to see that we are complying with federal privacy law.

C) Respond to organ and tissue donation requests. We can share health information about you with organ procurement organizations.

D) Work with medical examiner or funeral director. We can share health information 'with a coroner, medical examiner or funeral director when an individual passes away.

E) Address workers' compensation, law enforcement, and other government requests. We can share health information about you 1) for workers' compensation claims 2) for law enforcement purposes with a law enforcement official 3) with health oversight agencies for activities authorized by law 4) for special government functions such as military, national security, and presidential protective services.

H) Respond to lawsuits and legal actions. We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Changes to the Terms of this Notice

We can change the terms of this notice and the changes will apply to all information we have about you. The new notice will be available upon request in our office and on our website.

Effective Date: September 1, 2013
Review Date: July 1, 2017

If other, Please specify: