TO DIRECTORS OF YOUTH PROGRAMS/CAMPS FOR 2018
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- Blaise Hoover
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1 TO DIRECTORS OF YOUTH PROGRAMS/CAMPS FOR 2018 Watkins Health Services (WHS) wants to be your program s health care provider. WHS can provide youth program participants high quality health care. These services include: Medical evaluations, allergy injections, pharmacy, laboratory and X-rays. All of our healthcare providers are board certified and understand the needs of campers and the concerns of parents. If a camper comes to WHS for care, we will contact the parent or guardian as soon as possible. While we do prefer appointments to be scheduled, we certainly understand that issues arise which require prompt attention. Therefore, we have a Walk-In/Triage process to provide an immediate evaluation of the individual s needs. WHS has a treatment clinic where we can stabilize patients and transfer to an emergency room if required. Attached is a packet of forms that should be submitted to each participant s parent/guardian for completion. Please have the family return the packet to you so that IF a camper is brought to WHS for care, it can accompany the camper to ensure we have the best possible information on health history as well as emergency contact information. If the participant is never brought to WHS for care during your program, please return the packet of information to the parents. It is very important that your office NOT retain this medical information once your program has ended. Returning the forms provides assurances to the parent/guardian that personal health information is not being retained by your program and it removes your responsibility for secure storage or destruction of these records. There are charges for office visits as well as for any services ordered such as lab tests, X-rays, medications, etc. If any charges are to be billed to a commercial insurance company, a copy of the participant s insurance card(s) must also be provided. NOTE: We do not participate in or bill to Medicare, Medicaid, KanCare, or similar government programs so any charges in those programs and any balances not paid by insurance become the parent s/guardian s responsibility as noted on the enclosed Treatment Agreement. Youth program/camp participants often bring personal medications or medical devices to campus, which are sometimes forgotten and left behind when they return home. Many of these are quite expensive, so please be sure they are sent home with the participants, or mailed to them if medications or devices are found after the participants leave. Our Pharmacy by state law cannot accept any prescription medications or over-the-counter medications for disposal or mailing. For our Hours of Operation and other information, please visit our website: If we can be of further assistance or answer any questions, please feel free to contact WHS at Douglas Dechairo, M.D. Director and Chief of Staff Watkins Health Services Watkins Memorial Health Center 1200 Schwegler Drive Lawrence, KS (785)
2 Parent / Guardian Packet Health Services Information and Required Forms for Youth Program Participant Accredited by Accreditation Association for Ambulatory Health Care, Inc. Watkins Memorial Health Center 1200 Schwegler Drive Lawrence, KS (785)
3 TO PARENTS/GUARDIANS OF YOUTH PROGRAM PARTICIPANTS FOR 2018 Watkins Health Services (WHS) is the provider of health services at the University of Kansas. Occasionally, participants in youth programs/camps (i.e. campers) are brought to WHS for medical needs and we want to assure you that WHS will provide these campers with high quality medical care. All of our healthcare providers are board certified and understand the needs of campers and the concerns of parents. WHS will contact the parent or guardian as soon as possible. WHS has a treatment clinic where we stabilize patients and transfer to an emergency room, if required. WHS provides primacy care medical treatment and refers the patient back to their parent to arrange for follow-up care. We do recommend that you complete this packet of forms and submit it to the Youth Program Director. In the unlikely event that your camper requires medical care during the program/camp, the forms will be brought to WHS to provide important information about the camper s health conditions as well as emergency contact information. Please understand, there are charges for office visits as well as for any services ordered such as lab tests, X-rays, medications, etc. WHS will bill your insurance company, therefore a copy of the participant s insurance card(s) must also be provided. NOTE: We do not participate in or bill Medicare, Medicaid, KanCare, or similar government programs so any charges to those programs and balances not paid by insurance would become the parent s/guardian s responsibility as noted on the enclosed Treatment Agreement. If your camper is bringing any personal medication or a medical device to campus, please be sure that: 1) The camper fully understands how and when to take the medication or use the device; 2) The device or any remaining doses of the medication will return home with the camper at the end of the program as WHS is not allowed under state law to accept or dispose of such items. For more information about the services and healthcare providers at WHS, please visit our website: If we can be of further assistance or answer any questions about this packet, please feel free to contact WHS at Douglas Dechairo, M.D. Director and Chief of Staff Watkins Health Services
4 YOUTH PROGRAM PARTICIPANT S HEALTH HISTORY FORM This completed form must accompany the individual on first visit to Watkins Health Services (WHS). It is essential that our Treatment Agreement is signed by a parent or guardian. Name of Program / Camp: Name & Contact Information for Program s Director: Youth s Name Birth Date Sex Last First Middle Parent Name Best Phone # to call Address Street City, State Zip Emergency Contact, if other than above: Name _ Best Phone # to call Relationship to Youth Name of Family Physician Phone # 1. Does the youth have any significant illness or disability? NO YES If yes, please explain 2. Please check if the youth has or has had any of the following health conditions: Asthma Mental health Dizziness/fainting Diabetes Epilepsy/seizures Kidney problems Gastrointestinal problems Cardiac Headaches Other 3. Has the youth had any other significant illnesses, injuries, or surgeries? NO YES If yes, please explain 4. Medications and their dosages taken by the youth Name of Medication Dosage Frequency Reason Taken 5. Immunization History Please provide DATES for the following OR provide a copy of an Official Immunization Record Last Tetanus (Tdap) booster: (should be updated no longer than every 10 years) DTaP 1 st 2 nd 3 rd 4 th 5 th MMR 1 st 2 nd Polio 1 st 2 nd Meningococcal conjugate vaccine (MCV) Hepatitis A 1 st 2 nd Hepatitis B 1 st 2 nd 3 rd Chicken Pox (Varicella) 1 st 2 nd TB skin test Date of Negative Result OR Positive Result 6. Is the youth allergic to any medications? NO YES If Yes, please list 7. Does the youth have any other allergies? NO YES If Yes, please list 8. Do any allergies require an EPI Pen to accompany camper? NO YES If Yes, please list If necessary, please attach additional health information. AD WATKINS HEALTH SERVICES R- 12/27/2016 THE UNIVERSITY OF KANSAS
5 TREATMENT AGREEMENT FOR YOUTH PROGRAM PARTICIPANT WATKINS HEALTH SERVICES (WHS) AT THE UNIVERSITY OF KANSAS I acknowledge that I am the parent or guardian of the youth participating in a KU program/camp and that I am authorized to sign this document on behalf of the youth. I understand that if my camper requires healthcare services at WHS, I will be notified as soon as possible as to the type of care necessary in keeping with the laws of Kansas. I understand that WHS is not an Emergency Room but that they will stabilize and transfer all urgent and emergent conditions. I also acknowledge that if urgent/emergent care is needed, it may not be possible to notify me in advance of such care but that I will subsequently be contacted as soon as possible. CONSENT TO TREATMENT 1. I hereby consent to such health care as may be deemed necessary by the WHS providers including x-ray examination, lab tests, administration of medications, and any other diagnostic or therapeutic treatments. 2. I understand if an initial lab test indicates there is a need for additional testing, I will be contacted and encouraged to follow-up with our primary care provider. The WHS provider will explain when these tests may be needed. GENERAL CONDITIONS FOR TREATMENT BY WHS 3. I understand that WHS is not responsible for loss or damage to clothing, jewelry or other valuables in my camper s possession. 4. I acknowledge that the use of any video capturing devices (cameras, cell phones, etc.) by other than authorized personnel for official business is prohibited. 5. I will be respectful of all the healthcare providers and staff in WHS, as well as other patients. 6. I understand that upon my request, WHS will send a copy of the medical record to our primary care provider. INSURANCE ASSIGNMENT 7. I hereby assign all benefits payable under the terms of my insurance policy/healthcare coverage to WHS, and I authorize payment directly to WHS for any claim filed on behalf of the person for whom I am duly authorized to sign for insurance benefits. 8. I hereby authorize WHS to disclose to my health insurance carrier information from this youth s medical record as needed in presenting claims for benefits. ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY 9. I understand that WHS does not contract with all insurance companies and it is my responsibility to know if my insurance plan provides coverage for WHS services or requires a referral or pre-approval for such services. 10. Further, I understand that WHS is not a contracting provider for and cannot bill Medicare or any Medicaid program. If I have these types of government healthcare benefits, I am responsible for paying all WHS charges and it is my responsibility to seek reimbursement from these programs. *This is the healthcare coverage for my youth program participant: Insurance Company Claim Form Address Member I.D. # Group # Name of Policyholder Policyholder Date of Birth Address of Policyholder 11. I understand that I am financially responsible to WHS for any charges, co-pays and deductibles not covered by my insurance company. And, I understand that if I do not pay my bill within three billing cycles of the date of service, the overdue account will be sent to a collection agency. If I am the parent or legal guardian of the patient, I acknowledge that I will be financially responsible for unpaid charges. 12. If I do not want my insurance company/health plan billed or a statement sent for charges, it is my obligation to immediately advise the WHS Business Office. I understand that I may address any questions concerning my charges, coverage, billing or payments, to the WHS Business Office at: *PLEASE ATTACH A COPY (both front and back) OF THE HEALTH INSURANCE CARD FOR THIS PARTICIPANT! Print Name of Youth Program Participant Signature (Parent, Guardian or Representative) Print Name of Parent, Guardian or Representative Date Relationship to Participant Phone number for Parent, Guardian or Representative AD R-12/27/2016 WATKINS HEALTH SERVICES THE UNIVERSITY OF KANSAS
6 CONSENT FOR THE USE OR DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS In our Notice of Privacy Practices (NPP) we provide you information about how Watkins Health Services can use or disclose your youth program participant s medical information. As described in our NPP, we request your consent for any use or disclosure of medical information to carry out treatment, payment, or health care operations. You have a right to review our NPP before signing this Consent. It is available online: Or you may call and request that one be sent to you: By signing this Consent form, you: (1) Acknowledge that a copy of the NPP has been provided or offered to you; and (2) Consent to our use and disclosure of your participant s health information for treatment, payment, or health care operations, as described in the NPP. You have the right to revoke this Consent in writing at any time, except where we have already used or disclosed any health information in reliance upon this Consent. Print Name of Youth Program Participant Signature (Parent, Guardian or Representative) Print Name of Parent, Guardian or Representative Date Relationship to Participant Phone number for Parent, Guardian or Representative AD R-12/27/2016 WATKINS HEALTH SERVICES THE UNIVERSITY OF KANSAS
7 NOTE to Parents / Guardians: This is our standard Notice and is for your information only. You do not need to return this to the Program/Camp Director.
8
Parent / Guardian Packet. Health Services Information and Required Forms for Youth Program Participant
Parent / Guardian Packet Health Services Information and Required Forms for Youth Program Participant Accredited by Accreditation Association for Ambulatory Health Care, Inc. Watkins Memorial Health Center
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Summer Camp Health & Waiver Form
Summer Camp Health & Waiver Form 299 Episcopal Conference Center Rd, Waverly GA 31565 P. 912-265-9218 W. www.honeycreek.com This must be returned BEFORE camp begins. PLEASE PRINT CLEARLY. PERSONAL INFO
Patient Registration Form
2130 South 17 th Street Suite 100 Lincoln NE 68502 Phone: 402-454-7454 Fax: 1-402-513-6547 (the 1 must be dialed when faxing to our office) Email: admin@genesispsychiatricgroup.com Patient Registration
Mailing Address City State Zip Code. Employer City State Zip Code. How did you hear about us? Circle one
PATIENT REGISTRATION PATIENT Name (Last, First, MI) Sex M F Birthdate Social Security Number Marital Status- M S W Mailing Address City State Zip Code Employer City State Zip Code Home Phone Cell Phone
NEW PATIENT INFORMATION FORM
3271 N. Milwaukee St. Boise, ID 83704 tel: (208) 629-5374 fax: (208) 629-5394 www.theicim.com NEW PATIENT INFORMATION FORM Personal: Last Name: First Name: Middle Initial: : Address: City: State: Zip:
Medicine and Surgery of the Foot PATIENT INFORMATION PERSON RESPONSIBLE FOR PAYING THE BILL FAMILY PHYSICIAN INFORMATION HEALTH INSURANCE INFORMATION
PATIENT REGISTRATION Thank you for choosing our office! Please complete all pages. Patient Name: PATIENT INFORMATION Home Address: City: State: Zip: Sex: S S#: Marital Status: S,M,O or minor E-mail: Home
Prairies to Peaks Iron Horse Rail Summer Camp REGISTRATION AND HEALTH FORM
Prairies to Peaks Iron Horse Rail Summer Camp REGISTRATION AND HEALTH FORM Section 1 Basic Contact Information Campers Name: _ Nickname:_ Birth date / / Gender: Male Female T-shirt size: Adult / Youth
HIGHLAND PARK FAMILY PRACTICE, LLC ARTHUR H. MILLER MD, FAAFP 505 RARITAN AVENUE HIGHLAND PARK, NJ TEL:
HIGHLAND PARK FAMILY PRACTICE, LLC ARTHUR H. MILLER MD, FAAFP 505 RARITAN AVENUE HIGHLAND PARK, NJ 08904 TEL: 732-393-1331 www.hpfamilypractice.com PATIENT INFORMATION: Patient s Name (Last) (First) (Middle)
OUR POLICIES. Prior Authorization for prescriptions is $10.00 for each authorization completed.
OUR POLICIES Effective April 1, 2008, due to continued decreasing insurance reimbursements, we will begin strictly enforcing fees for certain tasks that we perform on behalf of our patients. Phone calls
Stat or Routine Exam / Procedure: Chart # Date of Exam: Age: Sex: Date of Birth: Patient s Name: Referring Physician:
Memorial MRI and Diagnostic Stat or Routine Exam / Procedure: Chart # Date of Exam: Age: Sex: Date of Birth: Patient s Name: Referring Physician: X-Ray / IVP, CT Scan, and Ultrasound: Patient History Have
Quick Patient Registration Form Patient Information:
Quick Patient Registration Form Patient Information: Legal First Name: MI: Legal Last Name: Sex: M F Date of Birth: Primary Language: Marital Status: Married Single Partner Divorced Widowed Race: Ethnicity:
NOTICE TO OUR PATIENTS
NOTICE TO OUR PATIENTS Although we participate with most insurance plans, you as the patient and/or insured party are responsible for co-pays, deductibles and any non-covered services, which are outlined,
PATIENT INFORMATION RECORD Title: (please circle) Mr. Mrs. Ms. Dr. other: Suffix: I II III IV Jr. Sr.
Providence Medical Park / 3841 Piper Street, Suite T300 / Anchorage, AK 99508 Alaska Regional Campus / 2925 DeBarr Road, Suite 250 / Anchorage, AK 99508 Ph: (907)-563-3103 F: (907)-561-1862 Mat-Su Regional
Please feel free to ask questions about this document. I have read the above guidelines and agree to the terms set forth by A Joint Effort PT.
Please arrive to your initial appointment at least 15 minutes early. For all following appointments, please arrive 5 minutes prior to you scheduled appointment time. To avoid waiting unnecessarily remember
FINANCIAL POLICY AND AGREEMENT
FINANCIAL POLICY AND AGREEMENT Our office is committed to providing excellent, affordable medical care. You have the right and responsibility of knowing the cost of your medical treatment. Should you be
Prior Authorization, Pharmacy and Health Case Management Information. Prior Authorization. Pharmacy Information. Health Case Management
Prior Authorization, Pharmacy and Health Case Management Information The purpose of this information sheet is to provide you with details on how Great-West Life will be assessing and managing your claim
PATIENT INFORMATION. Name of child Date of Birth Age Sex Last First Middle Preferred Name (Nickname) HomeAddress Street City State Zip
Welcome to! We are pleased to welcome you and your child to our practice. Please take a few minutes to fill out these forms as completely as you can. If you have questions we will be glad to help you.
PATIENT PROFILE. Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed. Address: City: Zip: Address: City: Zip:
![PATIENT PROFILE. Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed. Address: City: Zip: Address: City: Zip:](/thumbs/82/85694847.jpg "PATIENT PROFILE. Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed. Address: City: Zip: Address: City: Zip:")
PATIENT PROFILE PATIENT INFORMATION: Name: Date of Birth: Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed Address: City: Zip: Home#: Message#: Name of Primary Physician,
CROSSROADS HEALTH CLINIC Thank you for choosing us as your Health Care Provider.
PATIENT INFORMATION First Name: Middle Initial: Last Name: Mailing Address: Street Address: City: County: State: Zip: Phone #: Work: Ext: Would you like us to text you? Yes No Cell #: Driver s License
SUMON NANDI, MD NEW ENGLAND BAPTIST HOSPITAL 125 PARKER HILL AVENUE FOGG BUILDING, SUITE 501 BOSTON, MA 02120
SUMON NANDI, MD NEW ENGLAND BAPTIST HOSPITAL 125 PARKER HILL AVENUE FOGG BUILDING, SUITE 501 BOSTON, MA 02120 You have been scheduled for an appointment with Dr. Nandi. At your earliest convenience, please
ANNUAL WELLNESS AND PREVENTATIVE EXAMS
ANNUAL WELLNESS AND PREVENTATIVE EXAMS INFORMATION REGARDING BILLING AND INSURANCE Due to changes in health care laws, we are required to distinguish and bill separately for annual wellness exams and new
Your appointment with our office is scheduled on
Grand Rapids OB/GYN Dr Stephen C Dalm Nisha McKenzie PA-C Erin Walker PA-C 5060 Cascade Rd SE Ste C Grand Rapids, MI 49546 Phone (616)247-1700 Fax (616)247-3679 www.grandrapidsobgyn.com Welcome to Grand
Medford Foot & Ankle Clinic, P.C.
MICHAEL A. DEKORTE, DPM, FACFAS* RICK E. MCCLURE, DPM, FACFAS* JEFFERY D. ZIMMER, DPM Dear Patient, Thank you for choosing Medford Foot and Ankle Clinic for your podiatric care. Enclosed are the registration
West Cary Family Physicians 256 Towne Village Dr Cary, NC
New Patient Registration Form - page 1 PATIENT INFORMATION Patient s first name: Patient s middle name: Patient s last name: Patient date of birth: Patient sex: Marital status: single married Patient s
Sabates Eye Centers P.O. Box Kansas City, MO (913)
Sabates Eye Centers P.O. Box 26425 Kansas City, MO 64196-6425 (913) 261-2020 Type of Visit: u Routine u Medical Contact Lens Wearer? u Yes u No PATIENT INFORMATION Name (Last, First, Middle Initial) Date
Patient Information. Referred by: Primary Care Physician: Last Name: First Name: Mr. Mrs. Miss Other Middle Name: Preferred Name:
Patient Information Referred by: Primary Care Physician: Last Name: First Name: Mr. Mrs. Miss Other Middle Name: Preferred Name: Date of Birth: / / Age: SSN: - - Address: City: County: State: Zip: Email
Lawrence Eye Care Associates, P.A.
Dear Patient: Enclosed you will find paperwork that you will need to complete and bring with you on the day of your scheduled appointment. You will only need to complete this paperwork if you are a new
Last Name: First Name: MI: Date of Birth: / / Sex: Home#: Cell#: Address: City: Zip:
PATIENT REGISTRATION FORM DATE: PATIENT INFORMATION Last Name: First Name: MI: Date of Birth: / / Sex: Home#: Cell#: Address: City: Zip: Emergency Contact: Phone: Alt: Email: Primary Care PHYSICIAN Name:
THE BIOMECHANICS Physical Therapy and Sports Medicine Patient Information: Last Name First Middle Date of Birth / / / Employer s Name School
THE BIOMECHANICS Physical Therapy and Sports Medicine Patient Information: Last Name First Middle Date of Birth / / / Sex: M F Employer s Name School Contact Information: Mailing Address City State Zip
Patient Information Form
Patient Information Form Patient Name: Today s : Address: City: State: Zip: Home Phone: Cell Phone: Carrier: DOB: Age: Gender: Social Security Number: Employer Name: Occupation : Address: Email Address: