PATIENT REGISTRATION (0-17 YEARS)

Patient’s Legal First Name:

Patient’s Legal Last Name:

Patient's Middle Initial

Suffix:

Address: Street:

Apt #:

City:

State:

Zip:

Date of Birth

Social Security No:

Phone number to send remind text messages to:

E-mail Address for Patient Portal:

Parent/Legal Guardian:

If other, specify:

Date of Birth

Social Security Number:

Address (if different):

Email Address:

Cell Phone:

Home Phone:

Best Contact Number:

Cell Home

Parent/Legal Guardian:

If other, specify:

Date of Birth

Social Security Number:

Address (if different):

Email Address:

Cell Phone:

Home Phone:

Best Contact Number:

Cell Home

IN CASE OF EMERGENCY: (OTHER THAN THE PARENT/GUARDIAN)

Name of Emergency Contact Person:

Relationship to Patient:

Cell Phone:

Alternate Phone :

INSURANCE INFORMATION:

If not insured, please place N/A in required section.

PAY AT TIME OF SERVICE

PRIMARY INS. NAME:

Policy Holder:

Patient’s Relationship to Insured:

Policy ID#:

Group#:

SECONDARY INS. NAME:

Policy Holder:

Patient’s Relationship to Insured:

Policy ID#:

Group#:

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 (Patient or Parent if minor)

Relationship to Above Patient

Date:

Office Procedures and Policies

I give any doctor at Valencia Pediatric Associates permission to obtain lab, x-ray, or immunization information from any source for my child.

Financial Policy

Our relationship is with YOU, not your insurance company. Know your benefits. Inform us of changes and bring your new card in. We cannot bill without a valid card. If your insurance has lapsed and you do not give us your new information, you will be responsible for the bill. We encourage you to contact your insurance company to inquire about your benefits. Know, for example, if your insurance does not pay for check-ups which are less than 12 months apart. Know which labs, immunizations, and which hospitals are covered.

Valencia Pediatric Associates requires a credit or debit card be kept on file for all its patients.
Insurance companies require copays, coinsurance and deductibles to be collected at the time of service. We are not allowed to waive them or bill for them.
If a claim is denied, it is your responsibility to contact the insurance company and, if not paid, it is also your responsibility to pay it.
Additional issues addressed at well check appointments may be billed separately. Some insurance companies will not cover two office services on the same date so payment for one of them may be denied by the insurance company or an additional co-payment may be required.
If after drawing up a vaccine a parent/patient declines to have it administered, the cost for that vaccine will be patient responsibility.
If parents are divorced, whoever brings the child into the office is responsible for co-pays and for having a current insurance card.
School forms, letters, and copies of records are charged depending on the extent of work they entail.
I authorized and voluntarily consent to the participation and treatment of my child in a Telemedicine Consultation and or/ treatment with Valencia Pediatric Associates.
Physicals/ Well Check appointments must be cancelled within 24 hours or you will be charged a$75 fee.
Med Check appointments must be cancelled within 24 hours or you will be charged $55 fee. Acute/ Sick Appointments must be cancelled 30 minutes prior to scheduled appointment time or you will be charged a $40 fee.
New patient well check appointments must be cancelled within 24 hours or you will be charged$100.
All appointments not cancelled or missed, fees apply.
Returned checks incur a fee of $35.
I authorize the release of any information acquired in the course of treatment necessary to complete and file medical claims to my insurance company on my behalf.
I hereby acknowledge financial responsibility for costs of services rendered for me or for the person whose account I am acting as guarantor.
I agree to receive text messages from Valencia Pediatrics Associates for the purpose of communication with staff/ doctors. (There's no guarantee you will receive text messages.)

Acknowledgement of “Abuse Free Zone”

At Valencia Pediatric Associates we appreciate and respect our staff. It is our belief that our staff should have a work environment free from verbal and physical abuse. We expect each one of you to treat each one of our staff members as you would like to be treated. Outbursts against our staff will not be tolerated and may result in your discharge from the practice.

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.

Date:

Notice of Privacy Practices Acknowledgement

PLEASE REVIEW THE NOTICE OF PRIVACY PRACTICES

THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY, AS IT EXPLAINS:

How this office will use and disclose your protected health information.
Your privacy rights with regard to your protected health information.
This office’s obligations concerning the use and disclosure of your protected health information.

I acknowledge that I have received a copy of the office Notice of Privacy Practices. I further acknowledge that the office Notice of Privacy Practices is available at the front desk upon request.

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.

Date

Credit Card on File Policy

Your signature at the end of this document will indicate that you have read, understand and agree to the policies outlined below.

Valencia Pediatric Associates requires that a valid credit/debit card be kept on file for all its patients.
This policy is designed to:

Help you avoid all billing related fees.
Streamline the billing process in our office and eliminate the expenses related to handling overdue accounts.
Focus our time and energy on your children and their medical care.

Your card information is stored electronically and cannot be viewed by our office staff. Your signature will authorize the card to be used to charge for all patient related balances on your account.

How the policy works:

At the time of registration or check-in, you will be asked for your credit/debit card information. For those leaving an HRA/HSA credit card a secondary credit card is required.
If there is copay due, you can choose to use the card on file or another form of payment accepted by our office. If someone else brings your child in we will charge your card on file.
If you have a coinsurance or deductible due, you can choose to use the card on file or another form of payment accepted by our office. We have reimbursement rates on file for many insurance companies and do ask that you pay your portion at the time of service.
As before, we will bill your insurance company for all charges related to the visit. If your insurance company applies any additional patient responsibility amounts, we will charge the card on file for this amount.
We will also charge the card on file for missed appointment fees, medical record fees, form fees, or other services not covered by insurance.
All balances $500.00 or less will be charged automatically to the card on file. You will only be contacted prior to charging the card on file if the balance exceeds $500.00.
Once your card is charged we will publish the receipt to the Patient Portal (for those web enabled) or mail you a receipt of payment.

Please remember that this policy does not restrict your right to appeal any charge made to your credit card. Should you feel that we have charged your card in error, you may contact our billing office.

I have reviewed a copy of Valencia Pediatric Associates’ credit card on file policy and authorize them to keep my signature on file and to charge the below listed credit/debit card for balances not paid or covered by my child’s insurance carrier.

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.

Print Name as it appears on your Credit/Debit Card

Signature of Cardholder

Date:

Patient Name:

OFFICE USE ONLY

Please select credit card type. If your credit card is an HSA please select HSA along with the card type.

MC Visa Discover American Express HSA/FSA - MC HSA/FSA - Visa

Credit Card #:

Exp Date

CVV:

(Your CVV number is the 3 digits on the back of your credit card. Amex – 4 digits on the front)

Office Use Only: Manual/Swipe

Entered by

Date

SMS/Text Messaging Terms and Conditions

Purpose of SMS Communications VPA may send text messages regarding appointments, health updates, and wellness information.
Consent By signing, you agree to receive SMS messages at the number provided.
Message Frequency Message frequency varies depending on care needs.
Confidentiality & Privacy Texts may contain health information; SMS is not fully secure.
Costs Carrier message and data rates may apply.
Opt-Out Opt-out is not available; contact the office for communication preferences.
Liability VPA is not responsible for delays or failures in SMS delivery.
Parent/Guardian Acknowledgment I understand and consent to receiving SMS communications from VPA.

Child’s Name:

Date of Birth:

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/Guardian Name:

Signature:

Date:

LANES Opt-In / Opt-Out Authorization Form

Purpose of This Form
Your health care providers participate in LANES (Los Angeles Network for Enhanced Services), a secure electronic system that allows doctors, hospitals, and other health care organizations to share your medical information for your care. By signing this form, you give permission for your health information to be shared through LANES with other authorized providers.

Patient Information

Patient Name:

Date of Birth:

Your Choices

YES, I agree (opt-in) — I allow my health information to be shared through LANES NO, I do not agree (opt-out) — I do not want my information shared through LANES

Signature

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/Guardian/Patient Signature:

Date

Print Name of Representative:

Relationship to Patient:

Your information will be encrypted.