New Patient Package

NEW PEDIATRIC PATIENT HISTORY INTAKE

To our new patients: Welcome to Whole Care Pediatrics , PLLC. To help us establish you with our practice, please provide us with your complete health history: body, mind and spirit.

Personal History

MAIN PROBLEMS/ REASONS FOR THIS APPOINTMENT: (if possible, rank in terms of importance to you)

PAST MEDICAL, SURGICAL & TRAUMA HISTORY PERSONAL AND FAMILY HISTORY

Birth History:

Past Medical History:

OTHER PAST MEDICAL, SURGICAL & TRAUMA HISTORY

List prior illness, injury, hospitalization, surgery, and/or trauma:

Social History:

Diet:

Safety:

Family History:

List siblings:

Has any blood relative ever had the following:

GROWTH & DEVELOPMENT

EMERGENCY CONTACT:

(When guardian is unable to be reached)

(list 3 contacts)

This history record has been designed to facilitate our patients continuity of care at NW Pediatrics and Family Medicine, PLLC. This is a confidential record and will be kept in this facility. Information contained here will not be released to anyone without your authorization to do so.

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.

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.

Consent to Medical Care and Treatment of a Minor

CONSENT TO MEDICAL CARE AND TREATMENT OF A MINOR Clinics and hospitals are unable to treat or care for minors (children) without consent from parents or legal guardians. If a child has a medical emergency when parents or legal guardians are not readily available to provide consent, then problems can occur. Complete this form and leave it with the person who is responsible for your child in your absence. In case of a medical emergency, this form must be brought with the child to the clinic or hospital.

authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed by a licensed physician or hospital when, in the sole discretion of the attending physician, such care, treatment and procedures are immediately necessary or advisable in the interest of my child’s health and well-being. Under the circumstances set forth above, I elect not to be informed in advance of the nature and character of the proposed treatment, its anticipated results, possible alternatives, and the risks, complications, and anticipated benefits involved in the proposed treatment and the alternative forms of treatment, including non-treatment. Provided that proper photo identification and this written notice is presented, the following individual(s) are authorized to bring the aforementioned minor child to clinic visits.

CONTACT INFORMATION

INSURANCE INFORMATION

HIPAA (Health Insurance Portability and Accountability Act)

I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have rights to privacy regarding my protocol health information. I understand that this information can and will be used to:

Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. Obtain payments from third-party payers and conduct normal healthcare operations such as quality assessments and physician certifications. I understand that as part of my healthcare, Whole Care Pediatrics originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment.

I have received, read, and understand, or declined to read, your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. By signing our Consent Acknowledgement Form, you acknowledge you agree and fully understand the Health I nsurance Portability & Accountability Act.

Patient Acknowledgment

Office Policies

Welcome to Whole Care Pediatrics! We are so happy that you have chosen to make us your child’s medical home. We strive to create an atmosphere that is friendly and warm for our patients and look forward to taking care of your children for years to come. The practice is growing, and we would like to help the patients and parents make a smooth transition in regards to changes that will be taking place. We hope the following information is helpful in informing every one of our office policies and procedures and provides a more pleasant environment.

Sick and Well Waiting

We have provided sick and well waiting areas to help prevent the well children from being exposed to any illness the other children that are arriving for a sick visit may have. If you come to the office with more than one child and one of your children is sick, then you must report to the sick waiting room. Newborns and children here for well exams, rechecks, or follow-up exams from a previous illness who are no longer symptomatic should report to the well waiting room. Please help the spread of germs and keep your child in the sick waiting area if they are being seen for an acute sickness.

Sick Appointments: Acute sick appointments are scheduled as same day appointments only. There may be a wait time as we will be working you in between the regular scheduled appointments. Chronic sick appointments and consultations generally require more time than a standard acute sick appointment and will n eed to be scheduled two weeks or more in advance.

Well Child Appointments: We recommend scheduling well visits 6-8 weeks in advance. This assures that your child will have their well visit and immunizations on time. We recommend vaccines per AAP/CDC guidelines and follow all AAP guidelines for well child visits.

Cancellations: If you should need to cancel a pre-scheduled appointment, please notify our office 24 business hours in advance so that we may accommodate families who are on a waiting list for an earlier appointment. Failure to cancel your appointment within 24 business hours will result in a $25.00 charge. This charge must be paid prior to scheduling your next appointment.

No-Shows: There will be a no-show fee for every no-show appointment:

• Appointments not cancelled 24 hours in advance – Fee $25.00
• No show for standard length appointments – Fee $50.00
• No show for behavioral appointments (ADD/ADHD, Anxiety, etc.) – Fee $7 5.00

Failure to notify our office with a cancellation at least one hour prior to your appointment time will result in the above no-show fees. Our office policy states that 3 or more no shows are grounds for dismissal from the practice. This is not to be uncaring; it is an effort to continue prompt care throughout the day for our ill children. These charges will not be billed to your insurance company; you will be responsible for payment.

Late for Scheduled Appointments: If you are going to be more than 10 minutes late, please call our office so we can reschedule your appointment for a more convenient time. If your child is sick, you may wait in the office and be worked in between patients. Please note, there may be an extended wait time if you are late for your appointment.

Immunization Policy

Our physicians believe that all children should be fully immunized unless there are medical cont raindictions. We use the recommended timetable for vaccine administration per the American Academy of Pediatrics. We are committed to providing quality care and have a duty to protect our entire patient population. We have a duty to protect our newborns and other children with immune deficiencies.

Release of Medical Records

Our office has 15 business days to release your child’s medical records. There will be a $35.00 charge for copying your child’s chart for the first 30 pages, $0.25 for each additional page. Medical records may be transferred to another physician, pending an authorization release is obtained. This will be free of charge for the first transfer. Any additional transfers will result in the listed fees. We can also release your child’s medical records on a disc for a flat fee of $30.00 with no page limitations.

Shot Records/School Forms

Immunization records can be accessed and printed at any time from the patient portal found on our website. Immunization records will be released within 2-3 business days after request. Please allow 3-5 business days for your school, camp, and sports physical forms. There is a $10.00 charge for letters or forms needing more than a signature. Detailed forms and letters will be charged according to the amount of time required to complete. Please note that forms only requiring a signature can be signed during your office visits at no charge, so please bring them to your appointment.

Medication Refills

Please allow our office 72 hours for prescription refills. Medication refills will only be done during our normal business hours. The on-call physician will not prescribe non-urgent refills after hours or on weekends. Patients must be seen prior to filling any new prescriptions that our office did not originally prescribe. C ontrolled medications (such as those for ADHD) will require a visit every month until stable then every 3 months. Other prescriptions require a visit at least every 6-12 months, depending on the medication.

Please request prescription refills via your pharmacy

Threats

We apologize for having to express this up front in our office policy, but in the world today, we must maintain a zero-tolerance policy for verbal or physical threats made against our physicians or staff. If a threat is made either verbally or in written form, the physician-patient relationship has been compromised, and the patient (and any family members, if applicable) will be discharged from the practice.

Patient Acknowledgment

Telemedicine consent

Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.

1. I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.
2. I understand that I will not be physically in the same room as my health care provider. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room.
3. understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
   1. If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.
4. I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.
   1. I may revoke my right at any time by contacting [ Whole Care Pediatrics] at [281-984- 9480].
5. I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.
6. I understand that my health care information may be shared with other individuals for scheduling and billing purposes.
   1. I understand that my insurance carrier will have access to my medical records for quality review/audit.
   2. I understand that I will be responsible for any out-of-pocket costs such as copayments or coinsurances that apply to my telemedicine visit.
   3. I understand that health plan payment policies for telemedicine visits may be different from policies for in-person visits.

I understand that this document will become a part of my medical record.

By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand; and (3) am located in the state of Texas and will be in Texas during my telemedicine visit(s)

Patient Acknowledgment

NOTICE CONCERNING COMPLAINTS

Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address:

Texas Medical Board Attention: Investigations 1801 Congress Avenue, Suite 9.200 (physical address)

P.O. Box 2018 (mailing address) Austin, Texas 78768-2018

Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353 For more information, please visit our website at www.tmb.state.tx.us.

Registration Acknowledgement

I verify that this information is correct and up-to-date. I agree to update Whole Care Pediatrics of any changes to the information above. I understand that I am responsible for the charges accrued by my child/children regardless of insurance benefits. If, in using the information I have provided today or on previous occasions, Whole Care Pediatrics is unable to collect from my child’s insurance company, I accept full responsibility for the payment of my child/children’s bills. I also understand that if my insurance recoups payments I am responsible for all charges, even if more than a year has passed since the date of service.

I also understand that if there is a legal contract in a divorce situation where one parent is responsible for medical bill payments, that this is not a contract between you and our practice. In this instance, whoever is present for the visit with the patient is responsible for all copay, coinsurance, out of pocket expenses, or deductibles incurred on the date of service and remaining balance in the system.