MARTIN S PEDIATRICS AND FAMILY CARE: ADULT CHECK IN FORM

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1 MARTIN S PEDIATRICS AND FAMILY CARE: ADULT CHECK IN FORM NAME DOB: Food/Drug Allergies: Current Medications: Reason for Today s Appointment: PAST MEDICAL HISTORY Please check if you have any of the following: Asthma/Wheezing/Chronic Overweight/Underweight Coughing Diabetes Recurrent Pneumonia High Cholesterol Allergic Rhinitis/Hay Fever Thyroid Problems Eczema/Chronic Dry Skin Acid Reflux/Frequent Spitting Sinus Infection Chronic Recurrent Ear Infections Constipation/Diarrhea Recurrent Throat Infections Milk/Food Allergies Chronic Snoring Heart Murmur/Defect Apnea Abnormal Menstrual Cycles Hearing Loss Urinary Tract Infections Vision Problems Anemia Sickle Cell Trait/Disease Joint Problems Seizures Headaches Speech Delay Learning Disability Developmental Delays ADHD (Attention Deficit) Anxiety/Depression Chicken Pox /Measels/Mumps/ Rubella/Pertussis Please list any other illnesses: FAMILY HISTORY Please check if any family members have had any of the following: Asthma Acid Reflux/Heartburn Cystic Fibrosis Thyroid Problems Eczema/Chronic Dry Skin Diabetes Allergic Rhinitis/Hay Fever Overweight Milk Allergy/Lactose Heart Attack Intolerance Stroke High Cholesterol Anemia Sickle Cell Disease/Trait Blood Clotting Disorder Urinary Tract Problems ADHD Anxiety/Depression Chronic Headaches Please list any other illnesses: SOCIAL HISTORY Marital Status: Single Married Divorced Widowed Occupation: Education: College High School GED Other Number of Living Children: Do you smoke cigarettes? Yes No Occasionally Do you drink alcohol? Yes No Occasionally Do you use recreational Drugs? Yes No Occasionally Do you consume caffeine? Yes No Occasionally Do you exercise? Yes No Occasionally HOSPITAL INFORMATION Hospitalizations: No Yes (give reasons & date) Surgeries: No Yes (give reasons & type) Serious Injuries: No Yes (give type & date) of Last Physical Exam:

2 PATIENT INFORMATION LAST NAME FIRST NAME MI ADDRESS (MANDATORY): SOCIAL SECURITY NUMBER: MAILING/HOME ADDRESS: HOME PHONE# CELL PHONE# BIRTHDATE (Month/Day/Year) SEX RACE LANGUAGE SPOKEN AT HOME: RELATIONSHIP TO INSURED SELF CHILD OTHER: TYPE OF PRIMARY INSURANCE: POLICY NUMBER EFFECTIVE DATE PRIMARY INSURED INFORMATION LAST NAME FIRST NAME MI SOCIAL SECURITY NUMBER HOME ADDRESS (if different from patient) MAILING ADDRESS (if different from above) HOME PHONE# CELL PHONE# WORK PHONE# BIRTHDATE (Month/Day/Year) SEX RACE PRIMARY PHYSICIAN: MARITAL STATUS: EMPLOYED: STUDENT: MOM: YES/NO YES/NO DAD: YES/NO YES/NO EMPLOYER/MILITARY ADDRESS: NAME OF CONTACT PERSON PHONE# PHONE# TYPE OF SECONDARY INSURANCE: POLICY NUMBER EFFECTIVE DATE PROVIDE NAMES OF INDIVIDUALS WHO ARE AUTHORIZED TO BRING THIS PATIENT IN FOR VISITS: I authorize the release of any medical or other information necessary to process insurance claims for the services rendered Signature I authorize payment of medical expenses directly to this provider for services rendered. Signature

3 FINANCIAL POLICY Thank you for choosing Martin s Pediatrics and Family Care for your health care needs. The following is an explanation of our financial policy that we ask all patients/parents to read and sign prior to treatment so that we may better serve you and your family. Our main concern is that you receive the proper and optimal treatment needed to restore your health. Therefore, if you have any questions or concerns about our financial policy, please do not hesitate to ask. HEALTH INSURANCE: We will file with any insurance policy(s) provided to us. However, you must understand the following: 1. Should your insurance require a pre-certification or authorization, please make sure that you or your referring physician have obtained this prior to beginning treatment. Any charges incurred without the proper authorization will be the responsibility of the patient/parent. 2. You insurance policy is a contract between you and your insurance company, not Martin s Pediatrics and Family Care. All charges are ultimately the patient s responsibility. Not all services are a covered benefit, so please know and understand our policy. 3. Co-payments and deductibles are due at the time of service. AUTO ACCIDENTS: Whether it is your fault of not, we can file with your personal health insurance and you will be responsible for co-payments and deductibles associated with that policy at the time of service. If you do not have health insurance, or if you do not wish to file with them, you will be expected to pay a minimum of $20.00 per month until your claim is settled (at which time your payment is due in full). MEDICAID: We will file claims with Medicaid and any co-insurance companies that are provided to us. If you do not fall under any of the above categories, payment is due in full at the time of service unless previous arrangements have been made with management. We understand that temporary financial problems may affect timely payment of your balance. In this case, please communicate with our office and we will be happy to work out a payment agreement not to exceed 6 months from the date(s) of service. Again, thank you for choosing us as your health care provider. We appreciate your trust in us. For your convenience, we accept all credit/bank cards with the VISA and MASTERCARD logos. I have read, understand and accept the above financial policy. Patient/Parent/Legal Guardian Signature There is a $25.00 charge for all returned checks

4 MEDICAL INFORMATION RELEASE FORM (HIPPA Release Form) Name: of Birth: / / RELEASE OF INFORMATION [ ] I authorize the relase of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to: [ ] Spouse [ ] Child(ren) [ ] Other [ ] Information is not be released to anyone The Release of Information will remain in effect until terminated by me in writing MESSAGES Please call [ ] my home [ ] my work [ ] my cell number: If unable to reach me: [ ] you may leave a detailed message [ ] please leave a message asking me to return your call [ ] The best time to reach me is (day) between (time) Signed / / Witness / /

5 NOTICE OF PRIVACY POLICY Acknowledgment of Receipt of the Notice of Privacy Practices: I,, (a patient, parent, or legal guardian) hereby acknowledge that I was given the opportunity to review and request a copy of the Notice of Privacy Practices issued by Martin s Pediatrics and Family Care, on the date indicated below. Parent/Legal Guardian/Patient (please print): Signature of Parent/Legal Guardian/Patient: : List of Child(s) Name and of Birth: 1. Child s Name of Birth 2. Child s Name of Birth 3. Child s Name of Birth 4. Child s Name of Birth

6 REQUEST FOR RELEASE OF MEDICAL INFORMATION Patient: DOB: Address/Phone: I hereby authorize the release of my health information to: Martin s Pediatrics and Family Care in Jacksonville, NC From: Address: City/State/Zip: This data shall include: All records Labs Hospital discharge summary Medications X-rays Progress Notes Problem list Other Specific purpose of disclosure: Continued Care. Other: This consent shall be valid for (not to exceed one year). I certify that this authorization is made voluntarily and without coercion. I understand that the information to be released may include information regarding drug abuse, alcohol abuse, HIV infection, AIDS or AIDS related conditions, psychological, psychiatric or physical impairments. I understand that the information to be released is protected under State and Federal laws and cannot be re-disclosed without my further written consent unless otherwise provided for by the extent that action has already been taken to comply with it. Signed: : (Specify if signature is that of patient, parent, or legal guardian) Witness: :

7 Important Office Documents The mission of Martin s Pediatrics & Family Care is to provide the highest quality of medical care. To make this possible we adhere to a set of very important policies. Please read them carefully, initial all of the boxes and indicate your understanding and agreement by signing at the bottom. { } Late Policy: Late arrivals 15 minutes or later will be rescheduled so that other patients may be seen on time. The office may offer an appointment with the same or different provider however, there are no guarantees since openings due to cancellations or no shows are unpredictable. Please call if you will be late. { } 24-hour Advanced Notice Fee: If you wish to cancel an appointment we require a minimum of 24- hour notice, or a $25.00 fee will be charged. Proper notice allows another patient to make an appointment in place of yours and keeps the office operating at its most efficient level. Please be courteous and responsible. { } No-Shows Are Bad: If you fail to show for an appointment without notice we will require you to pay a $25.00 fee to continue your care here. Please contact our office as soon as you are aware that you will be unable to keep your appointment. After 3 no show occurrences we reserve the right to dismiss you from our services. { } Cell Phones: Cell phone use is restricted in our office. We realize emergencies may arise and therefore allow you to carry your cell phone during your appointment, however, please be courteous and set your phone to silent mode or turn it off when you are brought back from the lobby for care. { } Multi-Family Appointments: Our office does not schedule more than two family members on the same day. In the event, you schedule family appointments and fail to cancel within 24 hours you may not be permitted to schedule future family appointments on the same day. More than two missed appointments cause undue hardship on the schedule. We welcome families to the practice and our appointment schedulers will work with you to fit your needs as much as possible. Signature