IDENTIFYING INFORMATION
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- Sophia Pitts
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1 IDENTIFYING INFORMATION Child s Name: Date of Birth: Age: Address: City: State: Zip Code: Home Phone: Cell Phone: Mother s Name: Father s Name: Address: Siblings: Languages Spoken at Home: Caretaker s Name: SCHOOL INFORMATION Child s School: Grade/Teacher: Telephone: Child s Performance: Concerns: 1
2 REFERRAL SOURCE Who referred you to us? Telephone Number: Reason: CONCERNS What concerns you about your child s speech and/or language? LAST HEARING TEST Date: Location: Results: MEDICAL HISTORY Please list any chronic and/or acute illnesses and dates: 2
3 SURGICAL HISTORY Please list all surgeries, including type, dates, and where the surgery was performed: MEDICATIONS: Please list all medications taken by your child and what they are for: OTHER SERVICES: Does your child see any other professional or receive any other services (i.e. SLP, OT, PT, Psychologist)? If yes, please provide names, dates and reasons: What questions would you like answered as a result of today s visit? 3
4 DEVELOPMENT HISTORY Were there any problems before, during or after the pregnancy? If yes, please describe: Birth Weight: Type of Delivery: Vaginal C Section FEEDING HISTORY Was your child bottle or breast fed? Were there any feeding problems (i.e. fussy eater, nasal regurgitation, allergies, etc)? DEVELOPMENT When did your baby do the following? Please give an approximate age Say his/her first word: Put two words together: Speak in sentences: Sit up unassisted: Cruise: Walk: Potty Trained: 4
5 SOCIAL / EMOTIONAL HISTORY Please describe your child s personality: What activities does your child enjoy? 5
6 Department of Otolaryngology Head and Neck Surgery Financial Policy Welcome to the Department of Otolaryngology-Head & Neck Surgery. The following is a statement of our financial policy. We hope this gives you a better understanding of how our billing works. Financial Policy Patients have many different types of insurance and payment options for services rendered. Also, not all physicians in the practice accept the same type of insurance. The three most common scenarios are outlined below. Please read the following and if you have any question or concerns please call the office of the physician you are seeing. Participating Plans In this scenario the physician you will see participates with your insurance plan. It is your responsibility to ensure your physician is in fact currently a provider in that plan. At the time of service you will be responsible for all co-payments and coinsurances as outlined by your plan coverage. We will collect your co-insurances and deductibles in advance if you are having a procedure in the office or hospital. The Medical College will then forward a bill to your insurance carrier who will confirm if any additional payments are due from you. You will receive written notification of such decision and may ultimately be responsible for such payments as determined by your insurance company. If your plan requires a referral, please present the referral at the time you check-in. If you do not have a referral you may have to reschedule your appointment. Non-Participating Plans In this scenario the physician you will see does not participate in you insurance plan. Payment of services is due at the time of the visit. We can submit the claim directly to your carrier or a claim can be mailed directly to you. Medicare For any of our providers that participate with Medicare, we will bill Medicare directly for your service and Medicare will send payment directly to the physician. You will be responsible for any deductible or co-insurance. If your physician does not participate with Medicare you will be responsible for payment at the time of service, and your claim will then be forwarded to Medicare and they will reimburse you directly. Usual and Customary Rates Your insurance policy is a contract between you and your insurance company. Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company s arbitrary determination of usual and customary rates. Payment Cash, Check, MasterCard, Visa, Discover and American Express card are recognized forms of payment. We hope this information is helpful; Again, if you have any questions or concerns, please contact your physician s office. Signature of Patient or Responsible Party Date REV. 03/10/2016
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