New Patient Information Sheet Village Pediatrics, LLC

Transcription

1 New Patient Information Sheet Village Pediatrics, LLC Today s Date: Gender: Patient Information: Date of Birth: Last First Middle SS# Address: Home Phone: ( ) Street; Apt# City State Zip Parent(s)/Guardian(s) Information: (1) Relationship to Patient: Last First Middle SS# Address: Address: Cell Phone: ( ) Occupation: Work Phone: ( ) Work Address: (2) Relationship to Patient: Last First Middle SS# Address: Address: Cell Phone: ( ) Occupation: Work Phone: ( ) Work Address: In case of Emergency, please provide a name of a friend or relative: Phone: ( ) Relationship to Patient: Last First Health Information: Primary Insurance Secondary Insurance Company Name: Company Name: ID# ID# Group: Group: Address: Address: Subscriber s Name: Subscriber s Name: Subscriber s DOB: Subscriber s DOB: Subscriber s SS# Subscriber s SS# Copay: Copay: Office Policy I authorize Village Pediatrics, LLC to treat my child. I understand that payment is expected in full at time services are rendered by the person accompanying the child for treatment. If our office is a participating provider with your insurance carrier, a non-covered service(s), co-pay, and/or deductibles will be collected at time of visit. Arrangements for anything other than full payments at time of service must be made prior to your appointment. It is the responsibility of the guarantor to understand and accept guidelines set up within the individual s insurance plan. If you are unable to provide us with complete insurance information at the time of your visit you will be responsible for payment of services in full. I understand that I am financially responsible for any balance not covered by my insurance carrier, I have read and understand the office policy for payment and agree to the terms stated. Parent/Guardian Signature: Date:

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3 Village Pediatrics, LLC: New Patient Questionnaire Date: Patients Name: DOB: Newborn/Neonatal History: (Please Check/fill in appropriate information) Adopted: (Yes /No ) Any known history: (Yes /No ) If so please fill in the following. Pregnancy: Normal (Yes /No ) Number of week gestation Complications: Premature Labor Preeclampsia Infection Other Alcohol (Yes /No ) Smoking (Yes /No ) Substance use (Yes /No ) Medications/Vitamins Birth History: Home Birth ( ) Birthing Center ( ) Hospital ( ) Name of facility and Doctor/Midwife/Practitioner: Delivery Type: Normal Vaginal ( ) Forceps ( ) Suction ( ) VBAC ( ) C-Section Routine/Scheduled ( ) Emergency ( ) Please Explain: Birth Weight: Discharge Weight: Hepatitis B Vaccine given at birth (Yes /No ) Vitamin K (Yes /No ) Eye Ointment (Yes /No ) Blood Type: Mother Baby Coombs: Positive Negative Newborn Nursery ( ) Neonatal Unit ( ) Length of stay Breastfed ( ) Formula: which kind Feeding Problems Jaundice/Hyperbilirubinemia ( ) Phototherapy # day s Respiratory: TNN ( ) Pneumonia ( ) Ventilator ( ) CPAP ( ) O2 ( ) Infection: Group B Strep ( ) R/O Sepsis ( ) Antibiotics ( )# of day s Anemia ( ) Transfusions ( ) Newborn Screening Performed (Yes /No ) Circumcision (Yes /No ) Planning but not performed yet ( ) Hearing Screening (Pass /Fail ) Other Important information: Has your child had any of the following? (Please Check/fill in appropriate information) ENT: Ear Infections ( ) Hearing Loss (Left ) (Right ) Other ear issues Throat Infections ( ) Strep ( ) other throat issues Nose bleeds ( ) Allergic Rhinitis ( ) Chronic Sinus Infections ( ) Sleep Apnea ( ) Other Nose Issues Cardiac: Heart Defect ( ) Type Heart Murmur ( ) Type Arrhythmia ( ) Other Heart/Cardiac Issues Respiratory: RSV ( ) Bronchitis/Bronchiolitis ( ) Asthma ( ) Cystic Fibrosis ( ) Pneumothorax ( ) Pneumonia ( ) Type Required Hospital Stay(Yes /No ) Other Respiratory Issues Gastrointestinal: GERD ( ) Constipation ( ) Chronic Diarrhea ( ) Other Genitourinary: Hernia ( ) Hydrocele ( ) Bedwetting ( ) UTI ( ) VCUG/Ultrasound/Renal Scan (Yes /No ) Results/Procedures Dermatological: Skin Infections ( ) Eczema ( ) Acne ( ) Other Allergies: Medication ( ) Environmental ( ) Food ( ) Specify Endocrine: Diabetes: ( ) Type I ( ) Type II ( ) Age of Diagnosis Hypothyroidism ( ) Hyperthyroidism ( ) Other Hematology/Oncology: Anemia ( ), Bleeding Disorders ( ) Type Cancer ( ) Type Other Neurology/Psychology/Developmental: Seizures ( ) Type Low Tone ( ) Hyper Tone( )OCD( ) Cerebral palsy ( ) Autism( ) Asperger Syndrome( ) ADD/ADHD ( ) Bipolar Disorder( )Anxiety ( ) Delayed( ) Speech/Language ( ) Behavioral Issues ( ) Other Genetic Disorders: Specify (Over)

4 Surgery: (List dates/hospital/type) Hospitalizations: (List dates/hospital/reason) Injuries/Fractures: (Date/Treatment) Medications/Supplements: Past Present Immunizations: Up to Date (Yes /No ) Delayed (Yes /No ) Religious Exempt (Yes /No ) Education: Grade School Performance Additional Assistance Sports/Activities Pets: (Yes /No ) Type Does anyone in the Family smoke? (Yes /No ) Who? Inside or Outside? Social: Parents: Married ( ) Together ( ) Separate ( ) Divorced ( ) Blended family ( ) Child (children) live with Family History: List significant history and whether or not relative is on maternal (M) or paternal (P) side. Mother adopted ( ) Father adopted ( ) Heart Attack ( ) ( ) Stroke ( )( ) High Blood Pressure ( ) ( ) High Cholesterol ( ) ( ) Aneurysm ( )( ) Blood Disorders ( )( ) Diabetes ( )( ) Type: Juvenile/ Adult Obesity ( ) ( ) Alcoholism ( ) ( ) Other substance abuse ( ) ( ) Mental Illness: specify ( ) ( ) Other problems: List immediate family members, age and whether or not they have health issues: Any other information you would like to share? I have had the opportunity to review the Notice of Privacy and have no other questions. Signature Date Witness Date

5 Village Pediatrics, LLC 319 West Town Place, Suite 1 St. Augustine, FL Tel: (904) Fax: (904) Palencia location Paseo Reyes Dr. St. Augustine, FL Office Policy Our goal is to provide and maintain a good physician-patient relationship. Letting you know in advance of our office policy allows for a good flow of communication and enables us to achieve our goal. Please read each section carefully and initial. If you have any questions, do not hesitate to ask a member of our staff. Appointments: 1) We value the time we have set aside to see and treat your child. We do not double book appointments. If you are not able to keep an appointment we would appreciate 24 hour notice. There is a charge of $25 for missed appointments. 2) If you are late for your appointment (>15 minutes) we will do our best to accommodate you. However, on certain days it may be necessary to reschedule your appointment. 3) We strive to minimize any wait time, however emergencies do occur, and such will take priority over a scheduled visit. We appreciate your understanding. 4) Before making an annual physical appointment, check with your insurance company whether the visit will be covered as a healthy (well child) visit. Initial: Insurance Plans: Please understand: 1) It is your responsibility to keep us updated with your correct insurance information. If the Insurance Company that you designate is incorrect, you will be responsible for payment of the visit and to submit the charges to the correct plan for reimbursement. 2) If we are your Primary Care Physician, make sure our name or phone number appears on your card. If your insurance company has not yet been informed that we are your primary care physician you may be financially responsible for your current visit. 3) It is your responsibility to understand your benefit plan in regards to covered services, participating laboratory, etc. For example: a. Not all plans cover annual healthy (well) physicals, sports physicals or hearing and vision screenings. If these are not covered, you will be responsible for payment. b. For children less than 2 years of age there is a limit as to the # of allowable well visits per year. If the # of visits is exceeded, your Insurance Company will not pay; therefore you will be responsible for payment. 4) It is your responsibility to know if a written referral or authorization is required to see specialists, whether or not preauthorization is required prior to a procedure and what services are covered. Initial: Referrals: 1) Advance notice is needed for all non-emergent referrals, typically 3-5 days. 2) It is your responsibility to know if a selected specialist participates in your plan. 3) Remember we must approve referrals before they are issued. Initial: (over)

6 Financial Responsibility: 1) According to your insurance plan, you are responsible for any and all co-payments, deductibles and coinsurances. 2) Co-payments are due at the time of service. A $10 service fee will be charged in addition to your copayment if the co-payment is not paid by the end of that business day. 3) Self-pay patients are expected to pay for services in FULL at the time of the visit. 4) If we do not participate in your insurance plan, payment in full is expected from you at the time of visit. We will supply you with an invoice that you can submit to your insurance for reimbursement. 5) Patient balances are billed immediately on receipt of your insurance plan s explanation of benefits (EOB). Your remittance is due within 10 business days of your receipt of the bill. 6) If previous arrangements have not been made with our finance office, any account balance outstanding greater than 28 days will be charged a $10 re-bill fee for each 28 day cycle. Any balance over 90 days will be forwarded to a collection agency. 7) For scheduled appointments, prior balances must be paid prior to the visit. 8) If you participate with a high-deductible health plan, we require a copy of the health savings account debit/credit card or a copy of a personal credit card to remain on file. 9) We accept cash, checks, Visa and Master Card credit and debit. 10) A $25 fee will be charged for any checks returned for insufficient funds. Initial: Forms: 1) There is no charge for a blue and yellow form given at the time of your child s visit. This is considered part of the visit. However, should you lose your forms there is a $5 charge ($3 for one form) to replace them. 2) Any additional school, camp or sport forms are subject to a $5 per form fee. FMLA forms $25. Payment is due when the forms are dropped off. We require 3 day turnaround time. Initial: Transfer of records: 1) If you transfer to another physician we will provide a copy of your immunization record and your last visit to your physician, free of charge, as a courtesy to you. We need 48 hours notice. 2) A copy of your complete record is available for a $1 per page fee. 3) We provide records of your child for visits (including consults from specialists) rendered here at Village Pediatrics only. For any previous records, you must request them directly from your previous doctor(s). Initial: Prescription refills: 1) For monthly medication refills, we require 48 hours notice, during regular business hours. Please plan accordingly. Initial: I have read and understand this office policy and agree to comply and accept the responsibility for any payment that becomes due as outlined previously. Patient Name(s) Responsible party member s name relationship Responsible party member s signature Date Upon Completion we will provide you with a copy for your records.

7 Village Pediatrics, LLC 319 West Town Place, Suite 1 St. Augustine, FL Tel: (904) Fax: (904) Palencia location Paseo Reyes Dr. St. Augustine, FL Authorization to Release Medical Records Patients Name: Date of Birth: SS#: Address: City: State: Zip: Telephone Number: Date of Treatment: I, the undersigned, hereby authorize: (your former Pediatrician) Name: Location: Address: City: State: Zip: Telephone: Fax: The specific information to be used or disclosed is as follows: Complete Health Record Operative Reports Pathology Reports Laboratory Reports Radiology Reports Cardiology Reports Other Testing Results Emergency Room Discharge Summary I understand that this authorization is voluntary. I can refuse to sign this authorization. I understand that I have the right to inspect and copy the information to be used or disclose is pursuant to this authorization. I understand that once this information is received by the authorized person or organization then may be subject to redisclosure and may no longer be protected by federal privacy laws. I hereby authorize the above use and disclosure. Signature of Parent or Legally Authorized representative: Date:

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9 Village Pediatrics, LLC 319 West Town Place, Suite 1 St. Augustine, FL Palencia location Paseo Reyes Dr. St. Augustine, FL Permission to Treat This is permission that in my absence: Names: Relationship May seek, obtain and make any and all decisions for the emergency medical care of my child(ren), Parent signature Date:

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11 Village Pediatrics, LLC Credit Card Authorization I,, hereby authorize Village Pediatrics, LLC, to charge my credit card the balance of payment due Village Pediatrics, LLC after receiving notice from my insurance company. The amount charged is not to exceed the amount due. I also understand that I am responsible for payment of services should credit card be declined for any reason. Village Pediatrics, LLC will send a receipt of the charges along with an explanation of benefits. These documents are to be used should the insurance company audit any claims filed by Village Pediatrics, LLC. Name(s) of patients Date of service Name of cardholder Cardholder signature Credit card number Expiration date Security number (3digit code on back of card) Should you decline to provide credit card information, payment in full is expected at the time of service. Village Pediatrics, LLC (witness) Signature