Patient Demographics Patient Name Last: First MI Address City State Zip Sex Male / Female Date of Birth The following information is asked so that we can give personalized care to each patient: Preferred Language Ethnicity: (circle one) Hispanic or Latino Not Hispanic or Latino Unknown Race: (circle one) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race 1) Parent Information: (circle one) Mother Father Other (guardian, foster parent, etc) Last: First MI Date of Birth SSN Email Address Home Phone Cell Work Employer Address: Same as patient Yes / No (please circle one) Address City State Zip 2) Parent Information: (circle one) Mother Father Other (guardian, foster parent, etc) Last: First MI Date of Birth SSN Email Address Home Phone Cell Work Employer Address: Same as patient Yes / No (please circle one) Address City State Zip Sibling s names and ages:,,,, Primary Care Physician: (PCP) - In Case of Emergency Contact (Person not living with patient) Name: Relationship to Patient Phone How did you hear about our clinic: friend/relative, medical provider, phone book, billboard, internet search I authorize payment of medical benefits to the providers of Jim J. Gould, MD, PC. I also authorize the release of any medical information necessary to process these claims. I understand that regardless of insurance coverage, I am responsible for my account. The above information is complete and accurate to the best of my knowledge. Signature of Parent/Legal Guardian/Representative Date Relationship to Patient
Insurance Information Primary Insurance Company Name of Insurance Holder Address of Insurance Holder (if different from patient) Relationship to Patient Date of Birth SSN Policy Number Group Number Effective Date Claims Address City State Zip Secondary Insurance Company if applicable Name of Insurance Holder Address of Insurance Holder (if different from patient) Relationship to Patient Date of Birth SSN Policy Number Group Number Effective Date Claims Address City State Zip Tertiary Insurance Company if applicable Name of Insurance Holder Address of Insurance Holder (if different from patient) Relationship to Patient Date of Birth SSN Policy Number Group Number Effective Date Claims Address City State Zip Patient Name Date of Birth Sibling s names and date of birth that these changes pertain to:,,,,,. Signature of Responsible Party Date Relationship to Patient
Pediatric Health Questionnaire Patients Name: Date of Birth: Age: Sex: M F Primary Care Physician: Are you the parent or legal guardian for the child being seen today? Y N If not, do you have written permission allowing us to treat the child? Y N Is the child currently taking any medications (over the counter or prescription)? Y N If so, please list the medication(s) and the current dosage(s) Medication Dosage Medication Dosage Mother s Prenatal History (If Known) Number of pregnancies: Number of deliveries: Number of living children: Number of adopted children: Number of miscarriages: Please check any complications during pregnancy with this child: Have any children died? Y N Abnormal bleeding Accidents Blood transfusions Elevated blood pressure Elevated blood sugar X-rays Rash with fever Pre-mature labor Hospitalization Kidney infections swelling (eyes, face, hands) Venereal disease Excessive nausea/vomiting Were any medications other than Vitamins or Iron taken during pregnancy? Y N If yes, please explain: Neonatal History Did labor last longer than 24 hours? Y N Delivery timing: On Time (full-term) Early (pre-term) Late (post-term) How many weeks Gestation? Was child born: C-section Head first Feet first Buttocks first Did child require: Photo-therapy, Birth weight: lbs. oz. IV fluids/antibiotics, Oxygen, Prolonged hospital stay, NICU stay. Birth Length: inches. In the first six (6) weeks of life, did child have any of the following problems? Difficulty breathing, Blue spells, Yellow Jaundice, Vomiting, Loose stool, Colic, Formula changes, Fever/infections, Seizures, Weight loss, Blood transfusions, Surgery. Nutritional History Was child Breast fed? Y N. Until what age?. Any feeding problems? Y N. Does child have: constipation, diarrhea. Any current concerns about the child s nutrition? Y N If yes, please explain: Bottle fed? Y N. Formula brand? If yes, please explain:
Developmental History Did your first child develop normally? Y N If no, please explain: Any history of speech/language delay? Y N Any concerns with child s current development? Y N If yes, please explain: Immunization History Is child current on his/her immunizations? Y N. Any adverse reactions to previous immunizations? Y N When was child s last Tetanus booster vaccination? Past Medical History Has child had any of the following: ADD/ADHD Allergic Rhinitis Asthma Autism Behavioral prob. Bladder problems Bone problems Cerebral Palsy Chicken Pox Down Syndrome Eye problems Frequent UTI s Hearing problems Heart problems Intestinal prob. Kidney problems Muscle problems Pneumonia Rash/Eczema Recurrent Ear inf Roseola RSV Seizures Sinusitis Scarlet Fever Spina Bifida Stomach problems Strep Throat Diabetes Past Medical History (Continued) Please list any previous Emergency Room visits, hospitalizations or surgeries with dates: Medication/ food allergies and reactions: (If no known allergies, write NONE ) Family History Have any of the child s blood relatives had any of the following: ADHD Alcoholism Allergic Rhinitis Anemia Asthma Arthritis Birth defects Blindness Breast Cancer Cataracts Childhood Cancer Congenital Heart Disease Cystic Fibrosis Deafness Drug Dependencies Depression Diabetes Eczema Heart attack HIV/AIDS Hypertension Kidney Disease Leukemia Liver Disease Mental Retardation Lupus Migraines Multiple Sclerosis Psychiatric Sickle Cell Anemia Seizures Skin Cancer Stroke Thyroid Disease Tuberculosis Urinary Tract Infection Other: Information not known about biological family members. Social History These questions relate to the household in which the child lives: Number of siblings Birth order (first, middle, etc.) Smokers in house: Y N Number of dogs Number of cats Other pets Substance abuse: Y N. Discipline problems: Y N. Temper problems: Y N Deceased parents: Y N. Divorced parents: Y N State custody: Y N I certify that the above information is true and correct to the best of my knowledge. Printed Name: Relationship to Patient: Signature: Date:
Patient Consent for Use and Disclosure of Protected Health Information I hereby give my consent for Mountain West Pediatrics (MWP) to use and disclose Protected Health Information (PHI) about me to carry out Treatment, Payment and Healthcare Operations (TPHO). I have the right to review the Notice of Privacy Practices, which provides a more complete description of such uses and disclosures, prior to signing this consent. MWP reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by sending a written request to MWP at the above address. With this signed consent, MWP may call my home and any other locations for which I have provided contact information in order to relay or gather information to assist MWP in carrying out TPHO; including, but not limited to, appointment reminders, insurance and billing items, calls regarding my clinical care and laboratory results. MWP may give the message in person, leave a message on voice-mail or send the message via email to any email address I have provided to them. I have the right to request MWP restrict how it uses or discloses my PHI in order to carry out TPHO. Any such request must be submitted in writing to MWP. I understand that MWP is not required to agree to my requested restrictions, but if they does so in writing, they are bound to such agreement. By signing this form, I am consenting to MWP the use and disclosure of my PHI in order to carry out TPHO. I may revoke my consent at any time in writing, to the extent that MWP has already made disclosures in reliance upon my prior consent. If I do not sign this form, or revoke it at a later date, MWP may decline to provide treatment to me. Signature of Parent or Legal Guardian Date Patients Name (Please Print) Name of Parent or Legal Guardian (Please Print) Relationship to Patient Updated 06/13
FINANCIAL POLICY IT IS YOUR RESPONSIBILITY TO KNOW AND UNDERSTAND YOUR INSURANCE POLICY Insurance companies usually are not designed to pay the entire fees associated with an office visit. It is ultimately your responsibility to pay any remaining portion of your bill that is not paid by your insurance company. (Unless otherwise restricted by law or agreement we may have with your insurer). If your insurance requires a special claim form, we will allow two (2) business days for you to provide such form, after which time, we will process and send without it. Please notify us prior to visits if your insurance company does not cover immunizations or any other services that will be provided by our practice. Patients without insurance will be CASH accounts. Special arrangements can and will be made with large account balances whenever possible. FURTHER PATIENT TERMS OF FINANCIAL POLICY I understand that I am the responsible party for payment of medical services provided. Fees are due and payable at time of service. I authorize payment of medical benefits directly to Jim J. Gould, MD. I authorize use of my signature on all insurance claim submissions. Co-payments are due at time of service, as required by insurance company. I agree to pay any amounts not covered by my insurance. I understand that a finance charge of 1 ½% per month (18% APR) of unpaid balances will be added to my account. If any delinquent balance is placed for collection, I agree to pay an additional 50% collection fee and all associated legal fees, with or without suit. I understand a bounced check charge will be applied for all returned checks. The actual fee will be determined by the amount charged to MWP by my financial institution. I authorize Jim J. Gould, MD or any assistants to take my detailed medical history and to perform any necessary examination to confirm the condition for which I seek medical attention and to perform such procedures that are in their professional judgment necessary and/or desirable for my well-being. I hereby authorize the release of information necessary to process insurance claims and request payment of benefits to be made for services rendered. I agree to give 24 hours notice for any cancellation of appointments, and a fee of $25.00 will be applied to my account for missed appointments without prior cancellation. I understand that if I am more than 20 minutes late for a scheduled appointment, I may be asked to re-schedule. I understand that this office is HIPPA Compliant and a copy of the policy is available upon my request. By signing this form, I acknowledge that I fully understand and agree with the above policies and procedures. Signature of Parent or Legal Guardian Date Patients Name (Please Print) Name of Parent or Legal Guardian (Please Print) Relationship to Patient Updated 06/13