KIDS PLACE ORTHOPEDICS 3742 KATELLA AVE., STE 303, LOS ALAMITOS, CA 90720 ORTHOPEDIC HEALTH HISTORY Today s Date: Name Date of Birth Reason for Visit: Past Medical History: List your child s prior and current illnesses and injuries Past Surgical History/Hospitalizations: Current Medications: Medication and Food Allergies: Birth History: Born at weeks. Vaginal or C-section Breech? Yes No Pregnancy complications(y/n)list: Developmental History: How old was your child when they first sat crawled walked Social History: What grade is your child in? Does anyone in the house smoke? What sports does your child participate in? Family History: (List any health problems the parents or siblings see a doctor for) Review of Symptoms:(please indicate if your child has a health problem in any of these areas) General (fatigue, unexplained appetite or weight loss) Eyes (glaucoma, glasses) Ear/Nose/Throat (deafness, ear infections, sinus infections) Heart (murmur, irregular heart beat) Lungs (asthma, bronchitis, tuberculosis) Abdomen (hepatitis, colitis, severe constipation) Kidneys/Bladder (reflux, incontinence, urinary tract infections) Muscles/Bones (fractures, joint problems) Skin (rashes, burns) Neurologic (seizures, headaches, delay, shunt) Psychological: (ADHD, depression) Endocrine (diabetes, thyroid disease) Hematologic (anemic, leukemia, lymphoma) Infectious/Inflammatory Disease (HIV, eczema, latex allergy) Formed completed by Relationship to patient
PATIENT INFORMATION Patient s Last Name First Name Middle Initial Patient s Date of Birth Patient s Gender Patient s Primary Care Physician/Pediatrician PARENT/GUARDIAN INFORMATION Who has legal custody of patient? Mother Father Guardian Other, please list relationship Who does the patient live with? Mother Father Guardian Mothers/Guardians Last Name First Name Middle Date of Birth Mailing Address City, State, Zip Home Phone Work Phone Mobile Phone Fathers/Guardians Last Name First Name Middle Date of Birth Mailing Address City, State, Zip Home Phone Work Phone Mobile Phone EMAIL ADDRESS Other Emergency Contact Information Is this person authorized to bring child for medical treatment? Yes No Name Relation to Patient Home Phone Mobile Phone Who else is authorized to bring this child in for medical treatment?
Kids Place Orthopedics Financial Policy Thank you for choosing Kids Place Orthopedics as your healthcare provider. We are committed to providing your child with the best orthopedic treatment possible. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment. Participating Insurance Plans: We accept assignment on some insurance, but not all. Due to the frequent changes in health insurances, we are not able to keep up with the task of knowing all insurances, or your specific plan s details. It is your responsibility to confirm with your insurance whether or not Dr. Pike is in your network. Please remember that an insurance policy is a contract between you and the insurance company. We are not a party in that contract. We will file your claims to your insurance company. In order to do so, we must have a copy of your insurance card. We reserve the right to refuse to file claims to out of state insurances and secondary insurance. Upon request, we can provide you with a copy of a detailed receipt with which you may file your claim. Non-participating Insurance Plans: Patients who are insured by carriers that the practice does not participate with are considered self-pay. We offer a 10% discount for self-pay and cash patients. If your insurance pays for out of network providers, we will submit a bill to your insurance company for you. Referrals and Authorizations: If you have HMO insurance you must have an approved authorization to see Dr. Pike prior to scheduling an appointment. Co-payments: Co-payments, co-insurance, and deductible charges are due at the time of service. Our office accepts Visa/MasterCard or cash. If you are unable to pay at the time of service we will ask you to re-schedule your appointment. Durable Medical Equipment: Payment for durable medical equipment (tape, waterproof cast material, crutches, etc.) are due at the time of service. Self-pay accounts: Self-pay charges and balances are due in full at the time of the visit. Kids Place Orthopedics reserves the right to send overdue accounts to a Collection Agency. Patient Refunds: The following criteria must be met prior to Kids Place Orthopedics issuing a patient refund: 1) there are no outstanding insurance claims on the patient s account 2) there are no outstanding patient balances on the account. Financial Responsibility: A parent or legal guardian must accompany patients who are minors on the patient s first visit. This accompanying adult is responsible for payment of the account, according to the financial policy outlined on the previous page. If someone other than the parent or legal guardian will be bringing the patient to subsequent appointments, we must have a written consent to treat the child from the parent and the adult must bring payment for the visit. Medical Records: There is a charge for medical records. Records are $1.00 per page for the first 25 pages and.25 cents thereafter. Please allow 2-3 days to obtain school forms, 1-2 days for prescription refills and 4-7 days for other requests.
X-rays: There is a charge of $7.00 per print for copies of X-rays. Missed appointments: For rescheduling or canceling an appointment, please call our office 24 hours in advance. A $20.00 fee may be charged for missed visits that were previously confirmed. This financial policy helps the practice provide quality care to our valued patients. If you have any questions or need clarification of any of the above policies, please feel free to contact us. Consent to Disclosure of Protected Health Information I consent to the disclosure of my child s protected health information (PHI) for the purpose of treatment, payment, or health care operations. My child s PHI refers to health and demographic information collected from me and created or received by my provider, another health care provider, a health plan, an employer, a health care clearinghouse, or a third-party administrator. This PHI relates to my child s past, present, and/or future physical or mental health and identifies my child. I hereby authorize Kids Place Orthopedics to release my health information to my insurance company for the purpose of obtaining reimbursement for health care provided. I understand that I have the right to review the Kids Place Orthopedics Privacy Notice for a more complete description of uses and disclosures and that I have the right to review the notice prior to signing this consent. I understand that I have the right to request that Kids Place Orthopedics restrict how my child s protected health information is used or disclosed to carry out treatment and pay health care operations. I further understand that Kids Place Orthopedics is not required to agree to requested restriction(s), but if Kids Place Orthopedics agrees to a requested restriction, the restriction is binding on Kids Place Orthopedics. I understand that I have the right to revoke this consent in writing except to the extent that Kids Place Orthopedics has already taken action in reliance to this consent. I understand that Kids Place Orthopedics reserves the right to change the privacy practices described in its Privacy Notice and that I may obtain a revised notice by accessing the Kids Place Orthopedics Web site, calling the office and requesting that a revised notice be sent in the mail, or requesting one at my next appointment.
LIFETIME AUTHORIZATION FOR PATIENT OR RESPONSIBLE PARTY (A copy of this form will be considered acceptable as the original) I have read Kids Place Orthopedics Financial Policy and Consent to Disclosure of Protected Health Information, and agree to comply with the policies of this office. I authorize direct payment of medical benefits to Leah M. Pike, M.D, P.C/Kids Place Orthopedics for any and all services rendered to me. If any insurance claim is filed on my child s behalf, I understand that I am fully responsible for any charges not covered or paid by my insurance carrier. Any charge incurred to recover unpaid debts relating to my account will be my responsibility. AUTHORIZATION TO LEAVE MESSAGES I give my permission to the staff of Kids Place Orthopedics to leave messages on my telephone answering machine regarding my health care, insurance benefits, bills, or regarding an appointment. My signature below will acknowledge that I have carefully read the above statements and attached documents and agree with the content provided. Signature Date