New Patient Packet - First Copy

Please correct the errors described below.

MOTHER'S INFORMATION:

FATHER'S INFORMATION:

Insurance Information

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also give my permission for Southwestern Pediatrics to download and maintain my electronic prescription history for my medical treatment.

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.

Health History

Birth Development

Social History

Medical History

If yes, please provide the following information:

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Family Histroy

Select if any family member suffers from the following, and who; Example: Diabetes - Maternal Grandmother

Patient's sibling name(s) & age(s):

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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.

Medical Records Release

I authorize the release of photocopies of the following medical records and/or x-ray films/reports to the possession or control of Southwestern Pediatrics, its employees and/or agents of the purpose here of "Medical record" and "X-ray films" shall include ALL confidential "HIV related" information as defined in A.R.S. section 36-661, confidential "Alcohol or Drug Abuse" related information as defined in 42-CFR section 21 ET SEQ, confidential communicable disease related information as defined in A.R.S. section 36-3661 and confidential mental diagnosis and treatment information.

Medical Records to include:

  • Accute Illness Summary
  • Immunization Records
  • Graphic Growth Chart
  • Well Visit Evaluation Sheet/Forms
  • Hospital Discharge Summaries (if applicable)

This consent will expire 120 days after the signed date below. I have given my consent freely, voluntarily, and without coercion. I may revoke this authorization at any time, providing that notify Southwestern Pediatrics in writing to that effect. I understand that any release which was made prior to my revocation in compliance with this authorization shall not constitute a breach of my rights to confidentiality. I understand that a photocopy of this authorization is considered acceptable in lieu of the original.

I hereby authorize:

To send/release photocopies of medical records concerning the above named patient to:

Southwestern Pediatrics

21300 N. John Wayne Pkwy #112, Maricopa, AZ 85139

Ph: 520-568-9500, Fx: 520-568-9533

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.

Authorization for Release of Medical Information

I hereby authorize Southwestern Pediatrics to release photocopies of Medical Records concerning the above named patient to:

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I authorize the release of photocopies of the following medical records and/or x-ray films in the possession of control of Southwestern Pediatrics its employees, and/or agents. If further information is required we will be happy to provide to you the records at a nominal charge of $10 base fee and 25 cents for each page. When we are required to produce the chart for a second time, a $10 retrieval fee is required in addition to the above requirements. If you have personal records that you wish us to put in your child's chart, please make sure to retain a copy for your records. This consent will expire 120 days after the signed date below. I have given my consent freely, voluntarily, and without coercion. I may revoke this authorization at any time, providing that I notify Southwestern Pediatrics in writing to that effect. I understand that any release which was made prior to my revocation in compliance with this authorization shall not constitute a breach of my child's rights to confidentiality. I understand that photocopy of this authorization is considered acceptable in lieu of the original.

I understand that Southwestern Pediatrics DOES NOT release copies of records received form other Health Care Providers.

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.

ADVANCED WRITTEN CONSENT FOR FUTURE VISITS

Name of Person(s) receiving consent and relationship to the child:

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I hereby state I am the natural parent, legal guardian, or have legal custody of the above named minor and that I am authorized to consent to medical services on the minor's behalf. I hereby authorize Southwestern Pediatrics

All necessary or routine medical services

I hereby acknowledge that I understand and have had fully described to me the nature and risk/benefits of and alternatives to the above described proposed medical service(s) and have had all my questions regarding these service(s) answered to my satisfaction.

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.

Insurance/Financial Policy Patient Agreement

As a courtesy to our patients, we will file insurance claims for those insurances with which we participate. The agreement of the insurance carrier to pay for medical care is a contract between you and your insurance company. Any amount not covered by your insurance company is your financial responsibility. This includes co-payment, coinsurance and deductibles. This office is not responsible for disputing decisions made by your insurance carrier regarding coverage. It is your responsibility to notify our office when either your insurance plan or benefits change. All insurance contracts require us to collect deductibles, coinsurance and co-pay amounts at the time of service.

** IT IS YOUR RESPONSIBILITY TO BE AWARE OF YOUR INSURANCE BENEFlTS**

Payment

Payment will be requested at the time of service for all services which are non-covered or determined to be patient's responsibility, including co-payments, co-insurance and deductibles. (This is the policy of your insurance company)

We will kindly reschedule your appointment if you are unable to provide payment of co-pays, coinsurance, and deductibles.

Payment for past due balances for previous services rendered is also expected when you are seen in this office. We will be happy to set up a payment plan for you.

Delinquent accounts over 60 days will be sent to collections for processing. At which point all collection fees, contingent or not, shall be added to the patient's responsibility. In the event legal action is required, the patient shall be responsible attorney's fees and cost. Please remember we will be happy to set up a payment plan for you.

Appointment Policy

Southwestern Pediatrics strives to provide the best possible care and provide availability to each of our patients. Our policy is to charge $30.00 for each missed apPOintment unless it is canceled at least 24 hours in advance. Please help us to respect and better serve each patient in our office practice by making every effort to keep each of your scheduled appointments and by calling as early as possible when you must cancel or postpone an appointment.

I hereby authorize Southwestern Pediatrics to release information required by my insurance company for payment of my medical bills or to review activities related to my healthcare provider's participation in my health plan. I assign Southwestern Pediatrics any and all benefits to which is entitled for medical services rendered.

I HAVE READ AND UNDERSTAND THE ABOVE FINANCIAL POLICY AND I AGREE TO ABIDE BY ITS TERMS.

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.

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.

Vaccines for Children (VFC) Program Patient Eligibility Screening Record

A record of all children 18 years of age or younger who receive immunizations must be kept in the health care provider's office for 6 years. The record may be completed by the parent, guardian, individual of record, or by the health care provider. VFC eligibility screening and documentation of eligibility status must take place with each immunization visit to ensure the child's eligibility status has not changed. While verification of responses is not required, it is necessary to retain this or a similar record for each child receiving vaccine. Providers using a similar form (paper-based or electronic) must capture all reporting elements included in this form.

1. Child's Name:

3. Parent/Guardian/Individual of Record:

4. Primary Provider's Name:

5. To determine if a child (0 through 18 years of age) is eligible to receive federal vaccine through the VFC and state programs, at each immunization encounter/visit enter the date and mark the appropriate eligibility category.

Eligible for VFC Vaccine

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*Underinsured includes children with health insurance that does not include vaccines or only covers specific vaccine types. Children are only eligible for vaccines that are not covered by insurance. In addition, to receive VFC vaccine, underinsured children must be vaccinated through a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) or under an approved deputized provider. The deputized provider must have a written agreement with an FQHC/RHC and the state/local/territorial immunization program in order to vaccinate underinsured children.

**Other underinsured are children that are underinsured but are not eligible to receive the federal vaccine through the VFC program because the provider or facility is not a FQHC/RHC or a deputized provider. However, these children may be served if vaccines are provided by the state program to cover these non-VFC eligible children.

***Children enrolled in separate state Children's Health Insurance Program (CHIP). These children are considered insured and are not eligible for vaccines through the VFC program. Each state provides specific guidance on how CHIP vaccine is purchased and administered through participating providers.

Please be advised:

If your insurance company does not cover immunizations and you do not let us know at the time of the visit. it is your responsibility to pay the cost involved. We cannot make the Vaccines for Children Program retroactive and you are only eligible for the Vaccines for Children Program at the time of the visit. If you are unsure if immunizations and well check-ups are covered. please contact your insurance company. Thank You.

Please sign below indicating that you understand and agree with the above statement.

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.

Privacy Practices Acknowledgement

I have received the NOTICE OF PRIVACY PRACTICES and I have been provided the opportunity to review it.

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.

Active AHCCCS Members Only

If you are a member of any AHCCCS plan, you must notify us of any and all insurance coverage you may carry. We realize that insurance coverage can change frequently. This policy is intended to ensure that we provide the most accurate billing information to your insurance plan(s).

I certify that as of the date of my signature below I do NOT have insurance coverage of any kind other than AHCCCS.

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