Patient Information Form For all Patients 18 years of Age and Older Patient s Information Name: DOB: / / Male Female RACE African-American American Indian/Alaska Native Asian Caucasian Native Hawaiian/Pacific Islander Other Other Declined Unknown SS #: ETHNICITY Hispanic Not Hispanic Unknown Declined Street Address: City: Zip: Phone Numbers: Home: Cell: Work: Employer: Email: Preferred Method of Contact: Home Phone Cell Phone # Text: # Patient Portal Email **If you decline email communications then portal communications and appointment reminders may not be available. If you decline email communication please provide the reason: Insurance Company; Policy Holder s Name & DOB: PCP: NO INSURANCE Pharmacy & Phone #: Location: Please sign below to indicate that you have been offered an opportunity to review a copy of our HIPAA Notice of Privacy Practices. You are entitled to a personal copy of the notice at any time to keep for your records. If you have any questions about our Privacy Policy, please contact our Business Manager at 904-644-8669. Thank you for your cooperation. / Printed Name and Signature of Patient
PROCEDURES AND SERVICES AGREEMENT We will file the charges for the following procedures and services with the patient s insurance company, AS A COURTESY TO YOU. The insurance plan may or may not reimburse us for these procedures/services if they are performed in our office, or these procedures/services may not be covered by the insurance plan no matter where they are performed. Please note that if these services are not covered by the patient s insurance plan or are applied to the deductible, you will be financially responsible for the charges. All patients, parents or legal guardians have the right to elect for us NOT to perform these services in our office. We can present you with alternatives to have these services provided at another location (laboratory such as Quest, LabCorp, etc.) or we can direct you to a specialist for screenings. Services & Procedures Insurance Plans May or May Not Fully Reimburse For Labs, Screenings, Diagnostic Procedures Some insurance policies may or may not cover labs and screenings drawn or performed in our office. Some insurance policies may or may not cover particular labs, screenings, or diagnostic procedures ordered by us regardless of where they are performed. Fees not covered by the patient s insurance for these services will be the financial responsibility of the parent or legal guardian, if the patient is a minor. If the patient is 18 years of age or older, the patient will be financially responsible. The most common of these are listed below, although this policy applies to any Labs, Screenings, or Diagnostic Procedures regardless of whether they are listed or not. Vision & Hearing Screening when done as part of a physical Urinalysis when done as part of a physical Hemoglobin when done as part of a physical Lead Screen when done as part of a physical Hemocult Blood Stick Glucose Injections, Vaccines, & Fees for Administration of Vaccines Some insurance policies may or may not cover some vaccines or injections that are administered to our patients. Insurance policies also vary in whether or not they cover the administration costs for all vaccines or injections given. Each injection will be charged an administration fee. Charges not covered for these services and the vaccines or injections themselves will be the financial responsibility of the parent or legal guardian, if the patient is a minor. If the patient is 18 years of age or older, the patient will be financially responsible. Some of these are listed below, although this policy applies to any Injections, Vaccines, or Fees for Administration of Vaccines that are not listed. Rocephin Injections Decadron Injections Penicillin Injections Hormone Injections Vaccines/Immunizations Influenza Injections OR Intranasal Influenza Vaccine Administration Fee for EACH Injection or Intranasal application given Telephone Consultations Some insurance polices typically do not cover telephone conferences with providers to discuss problems or medial issues. Fees not covered by the patient s insurance will be the financial responsibility of the parent or legal guardian, if the patient is a minor. If the patient is 18 years of age or older, the patient will be financially responsible. I have elected to have all procedures and services listed or address above performed in the office of Tilak Pediatrics, regardless of whether reimbursement will be rendered by the patient s insurance or not. I agree to be solely financially responsible for the full cost of these services or the difference not covered by the patient s insurance company. Patient s Name Patient s of Birth If Minor, Printed Name of Parent/legal Guardian If Minor, Signature of Parent/Legal Guardian Signature of Patient, if 18 Years of Age or Older
AUTHORIZATION TO COMMUNICATE WITH OTHERS For all Patients 18 Years of Age and Older I, authorize: X Full disclosure to: Name of Patient (Please list name of Individual(s) you are authorizing us to communicate with regarding your medical treatment for yourself) Signature of Patient
CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION For all Patients 18 Years of Age and Older With my consent, Tilak Pediatrics may use and disclose Protected Health Information (PHI) about myself to carry out treatment, payment and healthcare operations (TPO). Please refer to Tilak Pediatrics Notice of Privacy Practices for a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices, prior to signing this consent. Tilak Pediatrics reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Judy Spinks, Business Manger, at 10175 Fortune Parkway, Suite 402, Jacksonville, FL 32256. With my consent Tilak Pediatrics may call my home or other designated location and leave a message on voice mail; with my consent may communicate via fax, secure e-mail or test message or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others. With my consent Tilak Pediatrics may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards, and patient statements. I have the right to request that Tilak Pediatrics restrict how it uses or disclosed PHI to carry out TPO. I do not have to sign this authorization in order to receive treatment from Tilak Pediatrics. In fact, I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the HIPAA privacy laws. Tilak Pediatrics has acted in reliance upon this authorization. My written revocation must be submitted to the Business Manager at Tilak Pediatrics. Patient s Name DOB: Signature of Patient
Authorization for Release of Protected Health Information (PHI) For All Patients 18 Years of Age and Older Patient Name: of Birth: PRINT Current Address: Phone #: I,, hereby authorize: PRINT NAME OF PATIENT TILAK PEDIATRICS Doctors Inlet Pediatrics Avenues Pediatrics 430 College Drive, Suite 100-102 10175 Fortune Parkway, Suite 402 Middleburg, FL 32068 Jacksonville, FL 32256 904-644-8669 Phone 904-519-0008 Phone 904-298-1973 Fax 904 379-7312 to disclose/release to to obtain from Name: Phone #: Fax #: Address: STREET CITY STATE ZIP (s) of Service Requested OR Full Record Release which may include information relating to communicable disease(s), Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV), genetic testing or screening, behavioral or mental health, alcohol/drug (substance) abuse or any such related information. RESPONSE REQUIRED Description of the purpose of the use and/or disclosure: --Change of Provider -- Second Opinion -- Emergency/Acute Care --Consultation -- Insurance -- Social Security/Disability --Legal Purposes -- Personal Use -- Other Describe I have carefully read this consent, understand its contents and authorize the release of the above specified information. I understand this Authorization will remain in effect for one (1) year, but I may revoke it in any time in writing. I further understand that any such revocation will not apply to any information already released under this Authorization. I understand that I am under no obligation to sign this Authorization and that my ability to obtain treatment from Tilak Pediatrics will not depend in any way whether I sign this Authorization. I understand that I have a right to receive a copy of this Authorization. I understand that information used or disclosed pursuant to the Authorization may be subject to redisclosure by the recipient and may no longer be protected by State and Federal privacy regulations. I hereby release Tilak Pediatrics from any and all liability related to their reliance upon this Authorization of the release of information pursuant to this Authorization. Signature of Authorized Party Relationship to Patient WITNESS 04/16
Doctors Inlet Pediatrics Avenues Pediatrics Privacy Notice In accordance with the Federal Health Insurance Portability and Accountability Act (HIPAA) of 1996, patients of this practice are entitled to the greatest degree of privacy possible. This office will strive to ensure that patient information is used only for authorized purposes as agreed to by the patient or parent/guardian. Parents/guardians/patients are advised that they have a right to review the patient s medical records in accordance with Florida statute 456.057 upon reasonable notice to the practice and during normal business hours, and to make comments to the same. The complete Notice of Privacy Practices is posted in our office waiting area. Please take a few minutes to read this document, as it contains very important information about how confidential health information is handled by our office. If you want a copy of this policy for your records please make your request to the staff and a copy will be provided to you. If you have any questions about our Notice of Privacy Practices please contact Robin Christopher, Practice Administrator at 904-298-1994. Patient Name: Acct. #: Parent/Guardian (if applicable) Relationship :
FINANCIAL POLICY PATIENTS 18 YEARS OF AGE AND OLDER We are committed to providing you with the best possible medical care. If you have special financial needs, we are willing to work with you. The following information is provided to avoid any misunderstanding or disagreement concerning payment for professional services. WE WILL FILE INSURANCE AS A COURTESY; HOWEVER YOU ARE ULTIMATELY RESPONSIBLE FOR YOUR CHILD S CHARGES. 1. Our office participates with a variety of insurance plans. It is your responsibility to: Bring your insurance card and photo I.D. to EVERY visit Pay your co-payment and/or any deductibles at EVERY visit.. Payment can be made by cash, check or credit card. We accept VISA, MasterCard and Discover. WE DO NOT BILL FOR CO-PAYMENTS Pay in full for any medical care or services that are not covered by your insurance plan 2. If you have insurance that we do not participate with, or you do not have insurance, payment is full is expected at the time of service. You will be a Private Pay patient in our office. (We do not accept new patients who are Private Pay but existing patients who lose their insurance can remain with the practice as Private Pay.) Payment must be made at time of service and includes a prompt payment discount. 3. If your insurance plan is an HMO or POS policy it may require you to choose a PCP (Primary Care Provider). You will need to choose a physician from our practice. If your insurance card lists the name of a physician who is not associated with our practice, we will see you but you will be Private Pay and required to pay at the time of service until the PCP has been changed to one of our physicians. 4. You are financially responsible for any amount not covered by your health insurance plan 5. You are financially responsible for all charges incurred during your care and treatment 6. If you have any questions about your insurance, we will be happy to try to help. However, specific coverage issues should be directed to your insurance company member services department. The telephone number is usually located on your insurance card. 7. If you fail (refuse) to make payment in full for rendered services, your outstanding balance will be sent to an outside collection agency. You will be responsible for any fees associated with the collection of your outstanding balance. Failure to meet your financial obligations with this office will lead to dismissal from the practice. 8. To protect your medical records, we ask you to provide our office with a valid driver s license or other photo I.D. Annually, or as changes occur, we will ask you to update and sign our Family Information Form. We will scan your insurance card, I.D., and Family Information Form, into your electronic medical chart. We will check these documents prior to releasing your medical information or medical records. We will take a picture of you for your electronic chart. This photo will help us identify you during routine functions. Your photo will not be released without your permission. LATE ARRIVAL/NO SHOW POLICY: Appointments are scheduled specifically for each patient. If you arrive more than 10 minutes late for your appointment, you may be asked to reschedule to another time, and possibly another day. If you cannot keep your appointment, we ask you to cancel at least 24 hours prior to the appointment time. If you no show (This term applies to missing an appointment completely or showing up for a scheduled appointment more than 10 minutes late) three times our policy is to discharge your child from the practice. MISSED OR CANCELLED APPOINTMENT POLICY: Appointments that are missed or not cancelled within the 24 hours window prior to the scheduled appointment time will be charged a missed appointment fee of $35.00. Tilak Pediatrics will not provide medical care to patients who refuse to sign and comply with our financial policy. SIGNATURE OF UNDERSTANDING: I have read, understand and agree to the above stated financial policies. / Printed Name Signature DATE ASSIGNMENT OF BENEFITS I, the undersigned, authorize payment of medical benefits to Doctors Inlet Pediatrics and Primary Care for any services furnished to me by the practice. I also authorize you to release to my insurance company or their agent, information concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims of benefits. This assignment shall remain valid until I provide written notice removing this Assignment of Benefits. Signature