Child's First name: D.O.B. Social Security #: Address (if different): D.O.B. Social Security #: Address (if different):

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Clinton Lyons
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1 Last Name: Street: Town: State/Zip: Date (today): Home phone: Mom cell: Dad cell: Dad's First Name: Dad's Last Name: Social Security #: Address (if different): Employer's Name: Employer's Address: Work phone: Occupation Mom's First Name: Mom's Last Name: Social Security #: Address (if different): Employer's Name: Employer's Address: Work phone: Occupation Primary Insurance Company: Insur ID#: Group #: Child is insured under (which parent): Secondary Insurance name, ID# and Group #: Name of alternate Emergency contact: Alternate contact home phone: Name of Dr. or person who referred you: Name and Address of Pharmacy you use: Cell phone: I herby authorize the release of medical records to my insurance company as may be necessary for the purpose of reimbursement. I realize that I am ultimately responsible for any and all serviced rendered to me (my child) regardless of any insurance determinations. Signature: Date:

2 PEDIATRIC AND ADOLESCENT MEDICINE MONDANA S. YAZDI, M.D., F.A.A.P. THERESA M. TORRES, M.D., F.A.A.P 219 EVERETT AVE. WYCKOFF, NJ TEL: FAX: CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS NAME BIRTHDATE I understand that as part of my healthcare, this organization 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 understand that this information serves as: A basis for planning my care and treatment. A means of communication among the many healthcare professionals who contribute to my care. A source of information for applying my diagnosis and surgical information to my bill. A means by which a third-party payer can verify that services billed were actually provided. A tool for routine healthcare operations such as assessing care quality and reviewing the competence of healthcare professionals. I understand that I have the right: To object to the use of my health information for directory purposes. To request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that the organization is not required to agree to the restrictions requested. To revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I request the following restrictions to the use or disclosure of my health information: PATIENT: X Signature of Patient or Legal Representative Date Witness Signature OFFICE USE ONLY: Accepted Denied Signature Title Date

3 FINANCIAL POLICY Dear valued patient, our office is committed to providing the utmost medical care for your children. We are pleased to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about our fees, our financial policy, or your financial responsibility. PARTICPATING INSURANCE PLANS We require you to bring your child s current insurance card at each office visit. All copays and balances are due the day your child is seen. There is a $10 fee added to your bill if the copay is not paid on the date of service. If your insurance company does not respond to our claim s submission, we will submit the claim a second time. If they have failed to pay after the second submission the balance will become your responsibility, and is due within 30 days of the billing. If your coverage was terminated and you do not present us with the new insurance card within 30 days of the date of service, the bill is your responsibility. If you plan does not require a copay and we participate with the plan, we will submit the bill to your insurance company. You are responsible for any deductibles and balance your plan indicates on their EOB (explanation of benefits). Some managed care organizations limit procedures and services in order to control costs. We will always provide your child with what we consider the best, most up-to-date medical care. Certain services such as vision screening, hearing, throat culture, urinalysis, etc. may not be paid by your insurance company and will become your financial responsibility. NONPARTICPATING INSURANCE PLANS If you have traditional indemnity insurance or are part of a plan with which we do not participate, our fee is due at the time the child is seen. We will provide you with an itemized receipt you can submit to your insurance company and they will reimburse you directly. MISSED APPOINTMENTS/LATE CANCELLATIONS Broken appointments represent a cost to us, to you and to the other patients who could have been seen in the time set aside for you. Cancellations are required 48 hours prior to the appointment. Unless we receive 48 hours notice, there is a $25 fee for missed check-ups. Excessive abuse of scheduled appointments may result in discharge from the practice. REQUEST FOR RECORDS There is a $15 charge for each medical record copied if you transfer from our practice and request your child s records. REQUEST FOR FORMS Blank forms will not be accepted. Parents have to complete their parts of the forms prior to form submission. Turn around time for form completion is less than 10 business days. Parents are strongly advised not to wait to the last moment to look at the paperwork they have received from the program their child is scheduled to attend. Due to HIPAA regulations, forms have to be picked up by parents only, we cannot fax or mail forms to you. The minimum charge for forms is $5 per child if forms are submitted together. The charge for college forms is $10. Rush service may be available for an additional $20 per child. PATIENT ACCOUNTS You are responsible for the timely payment of your account. If a balance is unpaid after 30 days there will be a $10 billing charge added each 30 day billing cycle until the balance is completely paid. Any patient balance left unpaid after 90 days, without any attempts at resolution, will be considered delinquent an may be submitted to a collection agency. If you are having financial hardship, please speak with Nina in our office and we will make every effort to set up an acceptable payment plan with you. Our front office staff does not have the authority to alter, reduce or waive charges. If an account is turned over to collection, we will be unable to provide any further medical care to your children. REFUNDS Overpayments will be refunded upon written request to the responsible party within 30 days. Date Name of Guarantor (please print clearly) Signature of Guarantor

4 Dr. Yazdi and Dr. Torres s Vaccine Policy Statement We firmly believe in the effectiveness of vaccines to prevent serious illness and to save lives. We firmly believe in the safety of our vaccines. We firmly believe that all children and young adults should receive all of the recommended vaccines according to the schedule published by the Centers for Disease Control and the American Academy of Pediatrics. We firmly believe, based on available literature, evidence and current studies, that vaccines do not cause autism or other developmental disabilities. We firmly believe that thimerosal, a preservative that has been in vaccines for decades and remains in some vaccines, does not cause autism or other developmental disabilities. We firmly believe that vaccinating children and young adults may be the single most important healthpromoting intervention we perform as health care providers, and that you can perform as parents/caregivers. The recommended vaccines and their schedule given are the result of years and years of scientific study and data-gathering on millions of children by thousands of our brightest scientists and physicians. These things being said, we recognize that there has always been and will likely always be controversy surrounding vaccinations. Indeed, Benjamin Franklin, persuaded by his brother, was opposed to smallpox vaccine until scientific data convinced him otherwise. Tragically, he had delayed inoculating his favorite son Franky, who contracted smallpox and died at the age of 4, leaving Ben with a lifetime of guilt and remorse. Quoting Mr. Franklin s autobiography: In 1736, I lost one of my sons, a fine boy of four years old, by the smallpox I long regretted bitterly, and still regret that I had not given it to him by inoculation. This I mention for the sake of parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it, my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen. The vaccine campaign is truly a victim of its own success. It is precisely because vaccines are so effective at preventing illness that we are even discussing whether or not they should be given. Because of vaccines, many of you have never seen a child with polio, tetanus, whooping cough, bacterial meningitis or even chickenpox, or known a friend or family member whose child died of one of these diseases. Such success can make us complacent or even lazy about vaccinating. But such attitude, if it becomes widespread, can only lead to tragic results. Over the past several years, many people in Europe have chosen not to vaccinate their children with the MMR vaccine after publication of an unfounded suspicion (later retracted) that the vaccine caused autism. As a result of under immunization, there have been small outbreaks of measles and several deaths from complications of measles in Europe over the past several years.

5 Furthermore, by not vaccinating your child you are taking selfish advantage of thousands o f others who do vaccinate their children, which decreases the likelihood that your child will contract one of the diseases. We feel such an attitude to be self-centered and unacceptable. We are making you aware of these facts not to scare you or coerce you, but to emphasize the importance of vaccinating your child. We recognize that the choice may be a very emotional one for some parents. We will do everything we can to convince you that vaccinating according to the schedule is the right thing to do. However, should you have doubts, please discuss these with us in advance of your visit. In some cases, we may alter the schedule to accommodate parental concerns or reservations. Please be advised, however, that delaying or breaking up to the vaccines to give one or two at a time over two or more visits goes against expert recommendations, and can put your child at risk for serious illness (or even death) and goes against our medical advice as health care providers. Such additional visits will require additional co-pays on your part. Furthermore, please realize that you will be required to sign a Refusal to Vaccinate acknowledgement in the event of lengthy delays. Finally, if you should absolutely refuse to vaccinate your child despite all our efforts, we will ask you find another health care provider who shares your views. We do not keep a list of such providers, nor would we recommend any such physician. Please recognize that by not vaccinating you are putting your child at unnecessary risk for life-threatening illness and disability, and even death. As medical professionals, we feel very strongly that vaccinating children on schedule with currently available vaccines is absolutely the right thing to do for all children and young adults. Thank you for your time in reading this policy, and please feel free to discuss any questions or concerns you may have about vaccines with any one of us. Sincerely, Mondana S. Yazdi, M.D. and Theresa M. Torres, M.D. Parents, as a simple acknowledgement that you have read this, please sign below: Date Signature of Mother Date Signature of Father

PATIENT DEMOGRAPHICS

CHILD INFORMATION 77 Elizabeth Drive 335 High St. Lockport NY 14094 Wilson NY 14172 Office # (716) 433-2674 Fax # (716) 433-2677 PATIENT DEMOGRAPHICS Patient Name Sex: M or F Last First Middle Date of