Patient Registration Form

Patient Information

Parent Information

Insurance Information

Primary

Secondary

Emergency Contacts

Communication

Consent For Medical Care

I state that I am the natural parent or legal guardian of the patient(s) listed above. If I am not available to give my consent in person, the following persons have my permission to authorize any and all medical treatment (persons listed on first page under Parent Information are automatically included). I understand that I must notify Celida Rangel, MD / Lisa Hunt, MD / Eduardo Marrero, MD in writing with changes of authorized caregivers. This consent is valid until revoked in writing.

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.

Privacy Practices

Dr. Celida Rangel, Dr. Lisa Hunt, and Eduardo Marrero, MD have provided a Notice of Privacy Practices for my review. I understand I may have a copy of the Notice upon my 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.

Office use only:

Financial Policy

I have read and understand West Phoenix Pediatrics, PLC ’s Financial and Office Policy, and agree to abide by its terms. This signature authorizes our office to treat my child and file appropriate insurance claims.
I agree to be financially responsible for any charges not covered by insurance.

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.

Photo Release Form

West Phoenix Pediatrics, PLC
We like to keep a patient photo as part of his/her medical record.
All medical records are protected and maintained per our privacy policy and upheld to HIPPA Standards.
By signing below, you allow a patient photo to be taken and updated periodically as part of the medical record

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.

Vaccines for Children Program

This record must be kept in the healthcare provider’s office to reflect the current status of all children 18 years of age or younger declared eligible to receive immunizations through the VFC program. The record may be completed by the parent, guardian, individual of record, or by the healthcare provider. This same record may be used for all subsequent visits as long as the child’s VFC eligibility has not changed. Provider verification of responses is not required, but it is necessary to retain this record on file for a minimum of three years.

Date of eligibility changes and updates

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 the 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 form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Financial and Office Policy

Dear Parent/Guardian,

Welcome! Please take a moment to review the following policies and procedures. We look forward to establishing a long and wonderful medical relationship.

Our office sees patients by appointment only. When making an appointment, please notify our scheduler of any changes in insurance, address, telephone number, or emergency contact. This eliminates unnecessary delays on the day of your appointment.

Walk-in and sibling add-on appointments will not be seen until the next available appointment slot. We want to take care of your child’s illness, but it is unfair to patients who have scheduled an appointment to ask them to wait while someone without a pre-scheduled appointment is seen. If you feel your child cannot wait to be seen, ask to speak to our staff.

If you are unable to arrive for your appointment on time, please call to inform the staff. We will review the schedule and determine if you can be seen when you arrive or if your appointment must be rescheduled. There is no guarantee you will be seen if you arrive past your appointment time.

If you are unable to keep your appointment, we require you to call and cancel as soon as possible, preferably 24 hours in advance. This allows another patient to schedule an appointment with our physicians. If you do not cancel your child’s appointment at least two hours before their appointment time, this will result in a “no-show” on the record and a $25 charge will be applied. Repeated “no-show” appointments may result in the family’s discharge from the practice.

We require that a legal guardian accompany a minor unless prior written authorization is given. The adult accompanying the minor is required to pay in accordance with our policies. We do not accept third party assignment nor do we recognize or enforce the terms of divorce decrees.

Payment is expected at each visit, whether it is a deductible, co-payment, percentage or payment in full. If you are waiting for coverage to become effective or have no insurance, payment will be expected at the time of the visit. For your convenience, we accept cash, checks, Visa, and MasterCard. There is a $30.00 charge for all returned checks. If your check is returned for insufficient funds, your payment options will be cash, credit card or certified funds (cashier’s check, money order, certified check) only.

Our office verifies insurance eligibility for every visit, but it is the parent/guardian’s responsibility to be familiar with the insurance plan’s financial coverage. Refer to the plan’s benefits booklet or website for questions about coverage. Be aware that an authorization from the insurance company for treatment is not a guarantee of payment. For any billing questions, please call 602-427-4992. We realize there may be financial hardship, if so please communicate this to our billing staff. Any accounts with outstanding balances greater than 90 days from the date of service may be sent to a collection agency and result in the family’s discharge from the practice.

Financial Policy

I have read and understand West Phoenix Pediatrics, PLC ’s Financial and Office Policy, and agree to abide by its terms. This signature authorizes our office to treat my child and file appropriate insurance claims.
I agree to be financially responsible for any charges not covered by insurance.

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.

If the above person is not financially responsible, please list:

Person listed is financially responsible Guarantor for all patients on this registration form. Unpaid balances will be sent to a collection agency. If the above Guarantor declines financial responsibility then I agree to be financially responsible.

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.