Registration Form

Patient Name

Date of Birth

Sex

Male Female

Race

White Black Asian Other

Hispanic

Yes No Decline

Address

City

State

Zip Code

Primary Contact #

Parent # 1

Date of Birth

Relationship to child

Home Address

City/State/Zip

Cell Phone #

Home Phone #

Work Phone #

How would you ideally prefer to be contacted regarding (check one)

Medical Issues

Home Phone Cell Phone Work Phone

Appointment Reminders

Home Phone Cell Phone Work Phone

Billing Statements

Home Address Patient Portal

Parent # 2

Date of Birth

Relationship to child

Home Address

City/State/Zip

Cell Phone #

Home Phone #

Work Phone #

May Parent # 2 have electronic access to children's records?

Yes No

Person Responsible for bill (guarantor)

Relationship to child

If the parents are divorced/separated who has custody?

Are there any legal restrictions on the non-custodial parent consenting to treatment or receiving medical information?

Yes No

If so, you must provide us a copy of legal paperwork.

In case of Emergency

Name of local friend or relative

Relationship to Patient

Phone Number

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Please list below additional persons who may bring the child to appointments, or who are authorized for us to communicate with regarding visits, medical information, ect. Example: Step-Parents, Grandparents, Nanny, Ect.

Contact Name (First/Last)

Relationship

Phone Number

Add new authorized person

Permission to treat a minor (under 18): In the event of an emergency and I cannot be contacted, I giver permission to Tri County Pediatrics to treat my child in their office as required by the events of that emergency situation.
E-mail permission: I authorize my e-mail to be used to send encrypted medical records, patient reminders, and patient statements.

Insurance Information

Primary Insurance Company Name

Subscriber Name

Date of Birth

Secondary Insurance Company Name

Secondary Subscribes Name

Date of Birth

I, the undersigned, understand that payment for all services is due at the time of service. Responsibility and payment shall be that of the guardian bringing the child for treatment. I understand that I am financially responsible for all charges whether or not paid by my insurance company and for any co-pay, deductible, co-insurance, or any other balance not paid by my insurance company. I understand that I am responsible for any cost incurred in the collection of patients account in case of default, including reasonable attorney fees and court cost. I understand that it is my responsibility to notify the practice of any changes in address or other contact information and any changes in insurance coverage and that payment for services shall be my responsibility if I fail to notify the practice of my correct insurance information. I hereby grant permission to the practice to release any pertinent information to my child's insurance company or their agent. I hereby assign to the Practice any insurance or other third-party benefits available for heath care services provided. I understand that the practice has the right to refuse or accept assignment of such benefits.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Notice of Privacy Practice (HIPPA)

As part of my health care, Tri County Pediatrics originates and maintains paper and/or electronic records describing patients health history, symptoms, examinations, test results, diagnoses, treatment and any plans for future care or treatment. This information serves as:

A basis for planning patient care and treatment
A means of communication among the many health professionals who contribute to patient care
A source of information for applying my diagnosis and surgical/treatment information to my bill
A means by which a third-party payer can verify that services billed were actually provided
A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

Consent to Disclosure of Patients Protected Health Information

I give this practice my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for heath care operations such as quality reviews.

I understand and have been provided with the practice Note of Privacy practice before signing this document.

I understand that this practice has the right to change their privacy practices and that I may obtain any revised notices at the practice.

I understand that I have the right to request a restriction on how my protected health information is used. However, I also understand that the practice is not required to agree to the request. If the practice agrees to my request, they must follow the restrictions.

I also understand that I may revoke this consent at any time, by making a request in writing, except for information already used or disclosed.

I understand by failing to sign or revoking this consent, the practice may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

I fully understand and accept the terms of this consent.

Guarantor Recognition of Fiscal Responsibility

I understand that I am responsible at the time services are rendered. I also understand that even though the office, out of courtesy, may verify my benefits, this is not a guarantee of payment. All benefits and eligibility are subject to change without notice. The benefits we verify are only a general summarization and are not intended to be used as an authorization of services provided. In the event my insurance does not cover all charges, I agree to pay the balance due in a timely manner. I am also responsible to notify the office of insurance changes.

Vaccine Policy

I understand Tri County Pediatrics strongly believe in effective communication concerning vaccine benefits and risks. They strive to stay on track with the vaccine schedule and encourage me to follow the time schedule that is given as it is recommended by the AAP and CDC. All vaccines are recorded in patients chart and reported to the Georgia Registry of Immunization to ensure that each patient's vaccination history remains current. No alternative vaccine schedule will be approved/allowed. Parents interested in alternate vaccine schedule may follow up at the Health Department. I understand If I refuse to vaccinate, I will have 90 days to reconsider my decision or my child will be released from the practice.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Your information will be encrypted.