Patient Registratin Frm Tday s Date: PATIENT INFORMATION Date f Birth: Sex: M F Hme Address: City: State: Zip: Patient Lives With: MOTHER FATHER BOTH OTHER: We are required t cllect the fllwing infrmatin fr each patient. Please cmplete this sectin befre returning the frm. Thank yu. Sibiling(s) f Patient Gender D.O.B Yur Preferred Language: PARENT/GUARDIAN INFORMATION PRIMARY FAMILY EMAIL: PRIMARY FAMILY PHONE: ( ) (OFFICE USE: LABEL AS MAIN ) Parent Date f Birth: Mbile Phne: ( ) Wrk Phne: ( ) Hme Address (if different frm child): City: Emplyer: Parent State: Zip: Date f Birth: Mbile Phne: ( ) Wrk Phne: ( ) Hme Address (if different frm child): City: Emplyer: Emergency Cntact State: Zip: Emergency Cntact Phne: ( ) Relatinship t Patient: Yur Child s Race/Ethnicity (select ne primary) American Indian Asian Black/African American Caucasian Hispanic Multiracial Unknwn Other Decline t answer FORM COMPLETED BY: Name (print) Signature Date
Primary Insurance Plan: Member ID Number: Effective Date: Plicy Hlder Plicy Hlder DOB: Relatinship t Patient: Sex: M F Secndary Insurance Plan: Member ID Number: Effective Date: Plicy Hlder Plicy Hlder DOB: Relatinship t Patient: Sex: M F
Patient Billing Guidelines Date: Hubbard Pediatric Grup (HPG) billing plicies and a representative list f items with ptential fees and charges are utlined belw. This infrmatin is t ensure yu are better infrmed at the time f service, and prir t the arrival f a billing statement. Please speak with the ffice manager if yu have any questins regarding this infrmatin. CO-PAYS/NO SHOWS It is ur plicy t cllect yur insurance c-pay at check-in. This simplifies the ffice prcess and ensures the financial bligatin is met at the time f service. After three (3) cnsecutive n shws the patient/parent will recieve a letter that may result in dismissal frm the practice. CO-INSURANCE/DEDUCTIBLES Every effrt is made t fairly estimate the c-insurance r deductible wed based n the nature f the visit. It is ur plicy t cllect these payments at the time f service. BILLING As a curtesy, Hubbard Pediatric Grup bills yur health insurance prvider n yur behalf, with the fllwing guidelines/exceptins: Insurance Card: It is critical that the mst current insurance card is brught t every appintment. We must have the crrect infrmatin at the time f service. An insurance card is similar t a credit card the infrmatin must be current and valid in rder fr it t be used. Aut Insurance: We d nt bill aut insurance fr visits and medical care related t an aut accident. Payment will be required at the time f service, and we will prvide the paperwrk needed fr yu t submit t the aut insurance prvider fr reimbursement. Secndary Insurance: HPG files secndary insurance, but we must have current and accurate infrmatin. COMBINED VISITS If yu are scheduled fr a well child exam, and ther health cncerns are brught up that wuld typically require a sick visit, yur insurance cmpany may cnsider these tw separate visits and bill yur c-pay and ther charges accrdingly. EVENING/WEEKEND/HOLIDAY SURCHARGE Sme health insurance prviders bill a surcharge if yu see yur pediatrician after nrmal business hurs, n the weekend, r n a hliday. ADMINISTRATIVE FEES HPG charges varius fees fr the fllwing items, which require persnnel and resurces t address: Cpies f medical recrds Cmpletin f sprts/camp physical frms Urgent Special Request physician letters Cmpletin f FMLA paperwrk Returned check (fr insufficient funds) Parent/Guardian Name (print) Signature Date
Hubbard Pediatric Grup
Hubbard Pediatric Grup Permissin t Treat a Minr/Authrizatin fr Treatment I (We) authrize Hubbard Pediatric Grup print name(s) f legal guardian(s) and its persnnel t deliver medical services t my child listed belw in the event f an emergency if I (We) can nt be cntacted. Date f Birth: I (We) authrize the fllwing peple t bring my child(ren) in fr treatment, and/r t cntact in case f an emergency: Phne: Phne: Phne: Relatinship: Relatinship: Relatinship: Signature(s) f Legal Guardian(s) Date *If Bth Parents Are Present, Bth Signatures Are Required* Relatinship t patient
*Office Plicies* After Hur Services and Phne Calls Our ffice ffers after-hur services. By calling (770)-710-0117 the n call dctr will either answer r receive the vicemail. The dctr will then advise r cntact yu t determine the next step. (treating by phne, meeting yu at the ffice, scheduling an appintment, etc.) Nurses Vicemail/Medicatin Refill Our nurses check their vicemail twice a day upn pening and after lunch. Messages left after 3pm will be turned n the next business day. Prescriptin refills will be called in daily. If an ADD/ADHD, depressin, r anxiety medicatin refill is needed, please call ur ffie t schedule an appintment. Unscheduled Visits/Walk-Ins Our schedule is nt set fr walk-in appintments. Please call ahead t establish an appintment time. Late Arrivals In rder t prvide yu with prmpt service and respect all ur scheduled patients, please arrive 5-10 minutes prir t yur scheduled appintment in rder t cmplete any required paperwrk, etc. If yu arrive mre than 15 minutes late fr an appintment yu may still be seen as a wrk in appintment r yu may be asked t reschedule the appintment based n the appintments f the day. N Shws Patients wh d nt shw up fr their appintment withut a call t cancel will be cnsidered as NO SHOW. Patients wh N-Shw three (3) r mre times in a 12 mnth perid, may be dismissed frm the practice thus they will be denied any future appintments. We understand that situatins arise in which yu must cancel yur appintment. It is therefre requested that if yu must cancel yur appintment yu prvide at least a 24 hurs ntice. This will enable fr anther persn wh is waiting fr an appintment t be scheduled in that appintment slt. In the event f an actual emergency and prir ntice culd nt be given, cnsideratin will be given, and an ne (1) time exceptin may be granted. Parent/Guardian Signature: Date:
Hubbard Pediatric Grup Acknwlegment Ntice f Privacy Practices 4495 Atlanta Hwy. Ste. 200 Lganville, GA 30052 Ph: (770) 710-0117 Fax: (470) 223-4229