Pre-registration required Vanessa Fax: (480)

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1 Pre-registration Pre-registering will save a considerable amount of time in the office. We hope this will make your visit more pleasant and efficient. In order to pre-register you will need to provide the information listed below. We also highly recommend that you download the New Patient Information Forms and complete them at your convenience. These will be required at your initial appointment. 1. Patient name 2. Insured s name (as it appears on insurance card) 3. Address 4. Telephone number 5. Social security number 6. Date of birth 7. Name of insurance company 8. Insurance company s toll free number for eligibility and benefits. 9. Insured or subscriber number 10. Group number 11. Card number 12. Effective date of insurance 13. Specialist co-payment amount 14. Medical Coverage (For example, Family Coverage or Single Coverage) 15. Referring physician 16. Diagnosis (for example, back pain, knee pain, etcetera) Please contact Vanessa in the office to remit the above information via fax to us. Unfortunately, we cannot accept this information by at this time. Fax: (480) We will contact your insurance company to verify your benefits. By verifying your benefits before your arrival it will save a considerable amount of time in the office. Please bring any MRI, CT scans or x-ray films that have been completed. This will hopefully provide the information necessary to complete an accurate diagnosis and allow a treatment plan to be promptly inititated.

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5 PEDIATRIC HISTORY FORM NAME / NOMBRE AGE / EDAD DATE OF BIRTH / FECHA DEL NACIMIENTO Weight/Peso Height/Alto A. BIRTH HISTORY / HISTORIA DE NACIMIENTO 1. Any problems with pregnancy? /Algun problema con el embarazo?? Yes / Si? No If yes, explain 2. Was baby full term? / Fue el bebe de tiempo complete?? Yes / Si? No If no, explain 3. Birth weight? / Peso al nacer? Birth Length / Cuanto B. GROWTH AND DEVELOPMENT / CRECIMIENTO Y DEARROLLO Age when first/ Edad cuando primer: Sat/ Se sento Walked / Ca mino Talked / Hablar C. SCHOOL HISTORY / HISTORIA ESCOLAR Year in school / Ano en la escuela: Nursery / Jardin de Infante Grades averaged / Promedio escolar School Name / Nombre de la escuela School Problems / Problemas en la escuela? D. MENSTRUAL HISTORY / HISTORIA MENSTRUAL Age 1 st menstrual period? / Edad cuando tuvo su primer periodo menstrual Date of first menstrual period/ Fecha su primera menstrual Date last menstrual period / Fecha del ultimo periodo menstrual Flow / Flugo? Light / Ligero? Med / Mediano? Heavy / Fuerte Do you have a period every month? / Tiene un periodo cada mes?? Yes / Si? No E. IMMUNIZATION HISTORY / HISTORIA DE LAS VACUNAS Up-to-date? Yes? No

6 Center For Spinal Disorders & Pediatric Orthopedics 1432 South Dobson Road, Mesa, AZ Suite #403 Phone Fax Patients Name: Today s Date: Date of Birth: I (Guarantor s Name) acknowledge I am responsible for any charges incurred under any the following circumstances: Co-pay, co-insurance, balance from processed Insurance claim(s) Expired/terminated insurance No insurance coverage Insurance will not authorize/approve visit and/or procedure / supplies Primary care physician/referral doctor does not carry AHCCCS insurance(s). I will be responsible for balance. (Print Name) (Date) (Signature) Financial Resp. 4-06

7 To Our Patients and Their Families: Thank you for choosing Center for Spinal Disorders & Pediatric Orthopedics as your provider of pediatric orthopedics and spine care. We value your decision and would like to take this opportunity to provide you with some information regarding the actu al costs that will be associated with your surgery and overall care. For an outpatient procedure (same day surgery), the following charges apply: 1. Surgeon 2. First Assistant (PA or RNFA) 3. Anesthesia 4. Hospital Operating Room (OR) time 5. Post Anesthesia Care Unit (PACU) time 6. Medications 7. Dressings For an inpatient procedure (overnight hospital stay), the following charges apply: 1. Surgeon 2. First Assistant (PA or RNFA) 3. Anesthesia 4. Hospital Operating Room (OR) time 5. Post Anesthesia Care Unit (PACU) time 6. Medications 7. Dressings 8. Daily hospital charges for admission to and for each day spent in the Pediatric Unit (Peds Floor) or the Pediatric Intensive Care Unit (PICU). We advise you to contact your insurance company to determine which costs are and are not covered under your plan. If you have any questions regarding your benefits, please call your insurance company s member services department directly. It is our commitment to you that we will use a hospital that is contracted with your insurance plan whenever possible. We will also do our best to schedule an Anesthesiologist and First Assistant that are credentialed with your insurance plan; however, there is no guarantee that we will be able to schedule your child s surgery with in-network providers. Our office staff will ensure that your insurance company is notified of any scheduled procedure and will obtain prior authorization as required. Please contact our Billing Manager at (480) with any questions you may have. Patient Name Parent Signature Date

8 CENTER FOR SPINAL DISORDERS & PEDIATRIC ORTHOPEDICS Notice of Privacy Practices To our Patients: This notice describes how health information about you as a patient of this practice may be used and disclosed and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Our commitment to your privacy Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated but we must provide you with the following important information. Use and disclosure of your health information in certain special circumstances: The following circumstances may require us to use or disclose your health information: 1. To public health authorities and health oversight agencies that are authorized by law to collect information. 2. Lawsuits and similar proceedings in response to a court or administrative order. 3. If required to do so by a law enforcement official. 4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat. 5. If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. 6. To Federal Officials for intelligence and national security activities authorized by law. 7. To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. 8. For Workers Compensation and similar programs. Your rights regarding your health information 1. Communications: you can request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home rather then work. We will accommodate any reasonable requests. 2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care, such as family members and friends. We are not required to agree to your request, however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. 3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Center for Spinal Disorders & Pediatric Orthopedics. 4. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Center for Spinal Disorders & Pediatric Orthopedics, 1432 S. Dobson Rd #403, Mesa, AZ You must supply us with a reason that supports your request for amendment. 5. Right to a copy of this notice. You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this notice at any time. To obtain a copy of this notice, please contact our front desk receptionist. 6. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Kathleen Brown, Center for Spinal Disorders & Pediatric Orthopedics, 1432 S. Dobson Rd #403, Mesa, Arizona All complaints must be submitted in writing. You will not be penalized for filing a complaint. 7. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. If you have any question regarding this notice or our health information privacy policies, please contact Kathleen Brown, Center for Spinal Disorders & Pediatric Orthopedics, 1432 S. Dobson Rd #403, Mesa, Arizona 85202, I hereby acknowledge that I have been presented with a copy of Center for Spinal Disorders & Pediatric Orthopedics s Notice of Privacy Practices. Signature Date Name of Patient