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Transcription:

Please Print Patient Information: Last Name First MI Address City State Zip - Home Phone Alt. Phone SSN Sex DOB / / Policyholder Information: Policyholder s Name Policyholder s Address Policyholder s DOB / / SSN Employer Business Phone Relationship to patient Insurance Information: Insurance Company Group Number Policy Number Co-Pay $

Responsible Party: (Please only fill out this part if the responsible party is different from the policy holder) Name Address Primary Phone Alt. Phone Relationship to patient Signature of authorized party Date As a courtesy to our patients, we will file your insurance claims. Please help us by providing us with accurate information.

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I understand that under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information (PHI). I understand that this information can and will be used to Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly. Obtain payment from third-party payers. Conduct normal healthcare operation such as quality assessments and physician certifications. I received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my PHI. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this information at any time to obtain a current copy of the Notice of Privacy Practices. Parent or Legal Guardian (please print) Name (Patient may sign if he or she is at least 18 years of age.) Signature...................................................................... Practice Use Only I attempted to obtain the parent s, legal guardian s, or patient s signature in acknowledgement of the Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below. Date / / Initials Reason

CONDUCT AGREEMENT The responsibility of the staff at Ramsdell Pediatrics is to provide a safe environment for you and your children. We will treat families with the courtesy, respect, and care that we would use to treat our own families. In return, we ask that you extend the same courtesy to everyone at Ramsdell Pediatrics, staff and patients alike. Violent behavior, language, cursing, and threats are treated very seriously here. Should you or members of your family behave in a way that is thought to be violent, threatening, or abusive, Ramsdell Pediatrics will not provide your pediatric care. Should you as a patient or family member witness violent or threatening behavior by staff or patient, please bring it to the attention of a doctor or manager immediately. Patient Name Parent/Guardian Date / /

AUTHORIZATION FOR RELEASE OF INFORMATION Name of Patient Date of Birth / / is authorized to release protected health information about the above named patient to the entities named below. The purpose is to inform the patient or others in keeping with the patient s instructions. Entity to receive information Check each person/entity that you approve to receive information. o Voice Mail o Spouse o Parent (provide name) o Other (provide name) Description of information to be released Check each that can be given to the person/entity on the left in the same section. o Results of lab tests/x-rays o Other o Financial o Medical, as follows o Financial o Medical, as follows o Financial o Medical, as follows Patient Information I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed as described in this document. I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. This authorization shall be in effect until revoked by the patient. Signature of Patient or Personal Representative Date / / Description of Personal Representative s Authority (attach necessary documentation)

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