PEDIATRIC PATIENT INFORMATION

PEDIATRIC PATIENT INFORMATION Due to new HIPPA regulations ALL information must be filled out, otherwise we will not be albe to process your claim and you will be billed for the medical services. LAST NAME: FIRST NAME: ADDRESS: CITY: STATE: ZIP: DATE OF BIRTH: / / GENDER: M F PARENT/GUARDIAN Please complete if Patient is a Minor PARENT/GUARDIAN NAME: DATE OF BIRTH: / / HOME PHONE: CELL PHONE: MAY WE LEAVE MESSAGES FOR YOU AT THESE NUMBERS? ADDRESS (If Different): CITY: STATE: ZIP: DO YOU AUTHORIZE THIS OFFICE TO DISCUSS YOUR CHILD S CARE OR TREATMENT WITH ANY PARTY OTHER THAN YOURSELF, INCLUDING FAMILY MEMBERS? IF, WITH WHOM? REFERRING PHYSICIAN NAME: PHONE NUMBER: HOW DID YOU FIND OUT ABOUT US? YELLOW PAGES INTERNET REFERRED BY PATIENT ADVERTISMENT INSURANCE REFERRED BY PHYSICIAN CONSUMER SEMINAR EMPLOYER OTHER 1

PATIENT INFORMATION Due to new HIPPA regulations ALL information must be filled out, otherwise we will not be albe to process your claim and you will be billed for the medical services. EMPLOYMENT EMPLOYMENT STATUS: FULL TIME PART TIME SELF-EMPLOYED RETIRED STUDENT OCCUPATION: MAY WE CONTACT YOU AT WORK: EMPLOYER: WORK PHONE: WORK ADDRESS: CITY: STATE: ZIP: INSURANCE INFORMATION PRIMARY INSURANCE CARRIER: POLICY HOLDER NAME (IF DIFFERENT THAN PATIENT) : DOB: INSURANCE THROUGH EMPLOYER: IF, EMPLOYER NAME: INSURED ID#: GROUP#: RELATIONSHIP TO PATIENT: SECONDARY INSURANCE CARRIER: _ POLICY HOLDER NAME (IF DIFFERENT THAN PATIENT) : DOB: INSURANCE THROUGH EMPLOYER: IF, EMPLOYER NAME: INSURED ID#: GROUP#: RELATIONSHIP TO PATIENT: 2

PATIENT INFORMATION Due to new HIPPA regulations ALL information must be filled out, otherwise we will not be albe to process your claim and you will be billed for the medical services. Authorization to Release Information and assignment of Benefits I authorize payments of medical benefits to the provider for the service rendered or to be rendered in the future without obtaining my signature on each claim submitted. I also authorize the release of any medical information necessary. I understand that I could be subject to a cancellation fee for each appointment missed where no notice is given or less than 24 hours of notice is given. I am responsible for all charges regardless of insurance coverage. If this account should be referred to a collection agency, I will be responsible for any collection and/or legal fees. I have read and understand this office policy and procedure. SIGNATURE: DATE: PARENT/GUARDIAN SIGNATURE: DATE: 3

Scheduling and Appointment: Arizona Balance and Hearing Aids, LLC is open from 8:00 to 4:30 Monday through Thursday, with the last appointment scheduled at 3:00. We are open on Friday from 8:30 to 12:00. Courtesy Calls: We make every effort to give a courtesy call as a reminder of scheduled appointments for the next day. Unfortunately, this is not always possible. It is the responsibility of the patient/parent/legal guardian to keep record of all upcoming appointments. In the event that a courtesy call is not made, the patient/parent/legal guardian is still responsible to keep the appointment or cancel at least 24 hours in advance. Cancellation Policy: Our audiologists want to ensure that you receive proper medical care, so it is out desire that you attend all scheduled visits. We understand that circumstances may arise prohibiting you from keeping your appointment. If you find that you are unable to keep your appointment we kindly request that you notify us at least 24 hours in advance. Failure to do so will result in a $50.00 to $75.00 charge to your account. In the event that you have had 2 missed appointments, we will have no choice but to dismiss you from our practice. Late Arrival: Please ensure that you are able to arrive at the office 15 minutes before your scheduled appointment. This will allow for out schedule to proceed smoothly. If you are late by more than 15 minutes, we will take you off the schedule and will have to accommodate you in the next available slot which will increase your wait time and sometimes require rescheduling. Insurance: In order to help you receive your maximum insurance allowable benefits, we need your assistance and understanding of our payment policy. We will require a copy of your insurance card in order to bill your office visit appropriately. We are required by law to obtain your signature for permission to release information to your insurance carrier. Our failure to obtain these updates could result in criminal and civil penalties and/or expulsion from your insurance plan. We will gladly submit fees for your covered medical services to your insurance company. However, we expect payment of all services within 60 days. It may become necessary for you to pay your account in full if your insurance company fails to pay for services within 60 days. It is your responsibility to understand your coverage and benefits, including pre-certification, referral and authorization requirements. We will, however, assist you to ensure that all plan requirements are met. X (Please Initial) Patient/Parent/Legal Guardian (Please Print) Patient/Parent/Legal Guardian Signature Date 1

Payment for Services: Payment for services, including co-payment and deductible amounts, are due at the time services are rendered unless payment arrangements have been approved by our billing office staff. We accept cash, checks, MasterCard and Visa. Our failure to collect these amounts is a violation of our contract with your insurance company and may result in civil or criminal penalties and/or expulsion from your insurance plan. In addition, your failure to pay the required co-amounts is a violation of your financial responsibility for coverage and we may report your refusal to pay these amounts to your insurance company. If you cannot furnish an insurance card at the time of the visit, you will be responsible for payment in full at the time of service. It is not the responsibility of our office to obtain this information for you. We will be happy to supply you with an accounting of the visit so that you may submit the information to your insurance company for reimbursement. X (Please Initial) Returned Checks will result in a $40.00 fee that will be posted to your account. Returned checks, balance older than 60 days, and failure to pay account balances as promised may be subject to external collection and additional fees, including attorney and other court fees. General: We will gladly discuss your proposed treatment and answer questions relating to your insurance. Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract. We must emphasize that as medical providers, our relationship is with you, not your insurance company. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. While filing of the insurance claim is a courtesy that we extend to patients, all charges are your responsibility from the date the services are rendered. X (Please Initial) We realize that temporary financial problems may affect timely payment on your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. My signature below constitutes acknowledgment and acceptance of this policy. Patient/Parent/Legal Guardian (Please Print) Patient/Parent/Legal Guardian Signature Date 2

PEDIATRIC CASE HISTORY Name: Age: Birth Date: EAR HISTORY Do you think your child has difficulty hearing? (Please circle one) If Yes, when did you first notice this and which ear(s)? Please circle or for the following questions: Frequent ear infections Frequent colds Ear Surgery (including tubes) Speech or language problems Family history of hearing loss BIRTH HISTORY Did your child pass their newborn hearing screen? Hospital Name: Mother s Full Name and Date of Birth: Pediatrician s Name and Telephone Number: At birth, did the baby suffer from/experience any of the following complications? (Please check all that apply) Jaundice Breathing/respiratory difficulties Cesarean birth Breech birth Premature birth Infection of baby or mother Low birth weight Low APGAR score Blue color Sucking/ swallowing difficulties MEDICAL HISTORY Please list any serious illnesses or injuries for which your child ever received treatment: Please list any current medications/ known allergies: DEVELOPMENT HISTORY Does your child s rate of development seem normal to you? (Please circle one) Has your child undergone any of the therapies listed below? (Please circle one) Speech/Language Therapy Occupational Therapy Physical Therapy Vision Therapy