First Name Middle Name Last Name Preferred Name PATIENT REGISTRATION Patient Information Byron C. Cotton, M.D., FAAP Gayla Woodson, MSN, CPNP First choice for infants thru young adult! First Patient Second Patient Third Patient Fourth Patient Date of Birth Sex (M or F)-Circle Male or Female Male or Female Male or Female Male or Female Primary Language Ethnicity- Circle Race - Circle Patient lives Mom - Dad - Both Parents - Mom - Dad - Both Parents - Mom - Dad - Both Parents - Mom - Dad - Both Parents - with: Other Other Other Other Primary Address: City State Zip code Mother / Legal Guardian / Other (circle) Name: Parent / Guardian / Responsible Party Information Birthdate Employer / Occupation Address (if different from above) City State Zip Phone Numbers Cell: Home: Work: Number to leave messages Circle: Cell / Home/Work Email Address Father / Legal Guardian / Other (circle) Name: Birthdate Employer / Occupation Address (if different from above) City State Zip Phone Numbers Cell: Home: Work: Number to leave messages Circle: Cell / Home/Work Email Address Emergency Contacts Name: Relationship to Patient: Phone Numbers Name: Relationship to Patient: Phone Numbers Additional Information For Patients 18 years of age or older please provide your Preferred Contact Number and Email Address to leave information regarding appointments, referrals, prescriptions, medical records and lab or test results: **Patient Number: Email address : How did you hear about us (Please Circle): ZOCDOC - Insurance Provider - Internet - Friend Referral- (? ) - Other Acknowledgments (Please sign below) HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) Please sign below that you have been offered the HIPAA Notice or an opportunity to review a copy of our HIPAA Notice. You are entitled to a personal copy of the notice at any time to keep for your records. *Signature of Parent/Guardian/Representative/Patient: Date: AUTHORIZATION TO MAIL, CALL, EMAIL, TEXT and Patient Portal: I understand the privacy risks of the mail, phone calls, emails, text messages and the Patient Portal. I authorize Kids & Teens Primary Healthcare staff to communicate with me by these means including but not limited to appointment reminders, referral arrangements, prescriptions, medical records and test results. I have the right to rescind this authorization at any time in writing. *Signature of Parent/Guardian/Patient: Date: CANCELLATION POLICY We ask that you provide a 24 hour notice for one child s visit and 48 hour notice for multiple children. I have been advised of the No Show Policy and fee effective 01/01/2018. After 1 No Show responsible party is required to pay a fee of $25.00 per no show. Nonpayment may results in Dismissal. *Signature of Parent/Guardian/Patient: Date:
Kids & Teens Primary Healthcare, P.C. Financial Policy We ask that you read this policy and aid us in keeping the costs down by ensuring that we are able to be reimbursed for our services on a timely basis. To help our office provide the most efficient and reasonable health care services, it is necessary for us to have a financial policy stating our requirements for payment of services provided to our patients. We are available to discuss our financial policy upon request. To help in this policy, we ask that you assist us by: 1. Providing us with current and updated information on yourself and your insurance company and to keep all changes up to date. It is your responsibility to notify our office of any change. 2. Make payment at the time of service for the entire balance if you are a self pay patient, or for the amount of any deductibles, co-pays, or past due balances that may be due. 3. Please do not discuss the financial aspects of your care with the provider(s). It is important for them to be allowed to practice medicine and provide patient care. Please work with the billing office staff on any account questions you may have. Patients are responsible for the payment of all services provided by our office. It is our policy to file for insurance as a courtesy to you if we have accurate and complete insurance information. Patients must provide all information requested by the insurance company within 10 business days of the request or the account may be collected as self pay and a refund processed if insurance reimburses at a later date. Since we are not a party to the agreement between you and your insurance company, we ask that you contact them in the event that services are not paid within a reasonable time frame, i.e. 30 days. You are also authorizing Kids & Teens Primary Healthcare and/or its employees to release any necessary information related to this visit and all future visits for the purposes of claim(s) payment. For SELF PAY patients, payment is due in full at the time of service. If we forward your account over to a collection agency, you will responsible for the entire balance on your account plus any collection agency, attorney, or court fees. Returned checks are subject to a $25 returned check fee. o I am authorizing the insurance company to pay any medical benefits for these services and all future claims to Kids & Teens Primary Healthcare and/or the Providers. o I am aware that the insurance is a contract between the covered party and the insurance company. It is my responsibility to be informed of my benefits. Benefits vary between contracts as well as their reimbursements and patient coinsurances. o I am aware that any balance due will require 100% payment or a payment plan may generally be set up for a period of 90 days. o I understand that if I fail to pay my account balance, it will be turned over to collections and I will be responsible for collection fees up to but not to exceed 33 percent of the balance. Parent / Guardian (Please Print) Signature Parent/ Guardian Date
Medical Forms Policy 1. Blank forms will not be accepted. Forms will ONLY be accepted after the patients name and other relevant information has been completed. To avoid a delay in processing please complete your portion prior to bringing in forms. 2. Turn around time for a form completion is usually fewer than 10 business days. However, parents and caregivers should realize that at certain times of year we may receive a larger quantity of forms than other times which may cause further delay. We will make every attempt to inform you of any such delay. Please remember that most forms have to be reviewed carefully by the Provider before it is released. Parents are strongly advised not to wait until the last moment to submit paperwork for completion. 3. Many forms require current health information from an examination within 6 to 12 months. We review this on an individual patient basis. You may be asked to schedule an appointment for an examination prior to forms being completed. 4. Forms are completed based on examinations conducted in our medical office. Our office will not sign off on forms based on services rendered by other offices. Therefore, you may be asked to schedule an appointment for examination. 5. There is no charge for Women, Infants and Children (WIC) forms. 6. The charge for review or completion of non-wic or medical forms ranges from $2 - $40 depending on the forms. The front office staff does not have the authority to alter, reduce or change charges. The fee is due at the time of the request. 7. Rush services for form completion to be expedited is available for an additional $5.00 to $10.00 depending on the time frame. Most expedited forms are then completed within 1-3 business days. Please understand that there may be times when the Provider is unavailable and this option may not be available. 8. Insurance companies DO NOT reimburse for form completion, and we DO NOT bill the insurance company for completion of forms. Parent Name: Date:
Kids & Teens Primary Healthcare Office Policies Phone 770-621-0245 Fax 770-621-0819 Website The office website is www.kidsandteenspc.com. We post any days that we will be closed during the month (except Sundays) as well as other helpful information under the Our News tab. The website has the option to send emails to the office for non urgent matters as well as make payments through the website. We accept Cash, Visa, Mastercard, AmEx, Money Orders, and Paypal Online. Medical Record / HIPAA We document all visits and always respect your privacy. Records requested for transfer to another physician, personal use, or sent directly to you will incur a charge, which must be paid before the records are processed. To request records, a medical record release must be submitted. Turnaround time is 7 business days. Urgent request will incur an additional fee of $5 with 3 days and $10 for 1 day completion. Scheduling Appointments Well checkups, follow-up and consultations are scheduled in advance. Sick appointments can be made the day your child is ill by calling as early as 8:00 AM. We accept walk-ins when we can accommodate them. To avoid waiting, or not being seen, please call first. For life threatening emergencies call 911. Please help us stay on time by arriving 5-10 minutes earlier than your appointment. If you are more than 15 minutes late you may be rescheduled for the next available appointment. If you need to cancel/reschedule an appointment, please be sure to call 24 hours in advance of the appointment for one child and 48 hours for multiple children. If you do not give advance notice, it will be considered a No Show. You will receive a warning after 1 (one) No Show and then you will be required to pay a fee of $25.00 per no show before scheduling another appointment. Referrals We often refer to a variety of talented, pediatric specialists in the area. We will almost always suggest you start with an appointment with us, although at times and for certain conditions we will make suggestions by phone. It is your responsibility to check with your insurance company and with the specialist to be sure your visit will be covered. Phone Calls Our front office staff are generally available to answers all calls generally between 8:30 am and 12:00pm and from 1:30pm until 4:30pm. Please be as clear as possible with information such as your child s name, date of birth, and the reason you are calling. You may be asked to leave the information on the nurse line for a return call. If you wish to speak to the doctor, the specifics will often be requested from staff to expedite a call back. As the provider is often seeing patients, they cannot always personally return a call. For some problems, the provider may request that you schedule an appointment. When calling about a sick child, always have the number of your pharmacy ready. As we have limited staff on Saturday, please hold all routine calls until the weekdays. After Hours A provider is available after hours for urgent and emergent medical needs by calling the main number. For calls that are not urgent, please call during regular office hours. We recommend that all parents learn CPR and keep emergency numbers handy. Rx refills We refill prescriptions during regular office hours. Call and leave a message, or have your pharmacy call or fax a request. Refills are done within 48 hours, unless authorization is required. We will notify you if there are any problems. You may be asked to leave this information on voice mail of the clinical staff. When calling, please specify type of medication. Patient's Code of Conduct As a parent or patient: You should provide the provider with accurate and complete information about your medical history and current condition You should ask for clarity if the provider s prescription and diagnosis seem unclear You should follow the Providers treatment plan and communicate if you are concerned that it isn't working You should pay your medical bills promptly You should treat the Provider and staff with respect You should not ask Providers or staff for false bills or certificates You should not engage in harassing or intimidating behavior, profane language, verbal or written threats or communications toward provider, staff, or others on Kids & Teens Primary Healthcare property. You should respect the privacy of other patients in the office by not lingering in the halls. Please help us keep our office clean so each visit can be an enjoyable experience for all: No Food Allowed, other than breastfeeding and formula for infants No cell phone use in exam rooms and hallways except for emergencies No smoking on the premises Dirty diapers must be taken out of the office ******************************************THANK YOU FOR YOUR COOPERATION Please list patient(s) you are responsible for below. Parent/ Responsible Party(s): *Signature Date: Print
CONSENT FOR PATIENTS WHO ARE NOT ACCOMPANIED BY A PARENT OR LEGAL GUARDIAN A parent or legal guardian must accompany all patients under the age of 18. The parent or legal guardian can designate another person 18 or older to seek medical care for their minor(s) by completing the information below. Mother: Father: Legal Guardian (please specify relationship): Please list patient(s) you are responsible for below for which this consent applies. I / We give consent for the following person(s) to accompany this patient(s), authorize treatment and make healthcare decisions as necessary. I further understand that anyone who brings the child besides the parents or legal guardian who is not listed below cannot authorize non emergency treatment for this patient(s). I understand that Emergency treatment as deemed urgent and necessary by the provider will be provided regardless of consent. I / We further understand that it is my responsibility to ensure that this authorization is updated as necessary. The person(s) named below are also allowed to: o pick up prescriptions Yes No o pickup forms Yes No o pickup Medical Records Yes No o request Medical Records Yes No o receive medical information including lab and tests results Yes No Please print: Parent/ Responsible Party(s): *Signature Date: Print