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1 TOO Patient Information Name of Minor/Child Last Name First Name Middle Name Nickname Sex: Male Female Date of Birth Social Security Mailing Address Street City State Zip Contact Number Home Mother Mobile Father Mobile Address Pharmacy Billing Information Father/Guardian Name Mother/Guardian (Maiden Name) Address (if different from patients) Home Phone Work Phone Date of Birth Driver s License Address (if different from patients) Home Phone Work Phone Date of Birth Driver s License Employer Social Security # Employer Social Security# Insurance Information Cardholder Name Date of Birth ID # Insurance Type Social Security # Group# Employer Emergency Contacts In the event of an emergency, who should we contact? (Someone other than parent/guardian) Work Phone Name Relationship Phone# Name Relationship Phone# Would you like to be a part of our Patient Portal? Yes No Address Name and Date of Birth of Siblings Release and Assignment Because your child is a minor, it becomes necessary that a signed permission be obtained from a parent/guardian before any and/or all necessary medical services can be started and accomplished by the physician at University Pediatric Association. I authorize the release of any medical or other information required in the processing of claims. I authorize my insurance benefits to be paid directly to the health care provider. My signature as parent/guardian affixed below authorizes the rendering of medical services. This consent shall remain in full force and effect until cancelled by either party. I understand that I am financially responsible for all charges incurred as a result of medical services rendered. Signature of Parent/Guardian Date

2 MANAGED CARE POLICY If you have a managed care plan, you need to be aware that most managed care plans require the policy holder to use certain laboratories, radiology or hospitals. If you do not, your plan will not cover the service. With several different plans, University Pediatric Association cannot be responsible to direct you to the facilities that are approved by your plan. It is your responsibility to know what your plan covers. Please read your policy or call your human resources department if you are unsure what facilities your plan covers. I have read the above statement and understand that University Pediatrics Association is not responsible for any procedures not covered by my insurance company. (Signature) (Date) FINANCIAL POLICY In order to reduce confusion and misunderstanding between our patients and the practice, we have adopted the following financial policy. If you have any questions about the policy, please discuss them with the billing office or the Patient Account Representative. We are dedicated to providing the best possible care and service to you and regard the complete understanding of your financial responsibilities as an essential element of your care and treatment. Unless other arrangements have been made in advance by either you or your health coverage carrier, full payment is due at the time of service. For your convenience, we will accept cash, check or money order. VISA, MasterCard and Discover will be accepted for payment of $10.00 or more. APPOINTMENTS There will be a $35.00 charge for missed appointments that are not cancelled 24 hours prior to the scheduled time. INSURANCE We have made prior arrangements with several insurers and other health plans to accept an assignment of benefits. We will bill those plans for which we have an agreement and will only require you to pay the authorized co-pay. It is our policy to collect co-pays for the pre-set amounts when you arrive for your appointment and check in with the receptionist. Our cashier will collect co-pays determined by a percentage upon completion of your visit. Any services that are not covered by a co-pay, are due in full at the time you check out. MEDICAID Medicaid requires all Medicaid recipients to always present their card when seeking medical attention. Failure to do so may result in the rescheduling of your appointment. If the visit is for a well check or immunization, the appointment will be rescheduled until proof of Medicaid is presented. RETURNED CHECKS A $30.00 service charge will be added to your account for all returned checks and must be paid before additional appointments will be scheduled. Restitution of the check must be made within 10 days or check will be given to the County Attorney for prosecution. COLLECTION AGENCY Any account that is given to our collection agency due to non-payment will have a 10% collection charge added to the account. Our collection agency will then collect the past-due amount plus the 10% collection charge. SERVICES RENDERED IN THE HOSPITAL We will bill your health plan for all services provided in the hospital. Any balance due is your responsibility and is due upon receipt of a statement from our office. If you are unable to pay in full, payment arrangements can be made. MINOR PATIENTS For all services rendered to a minor patient, we will look to the adult accompanying the patient and/or the parent or guardian for payment. I HAVE READ AND UNDERSTAND THE FINANCIAL POLICY OF THE PRACTICE AND I AGREE TO BE BOUND BY ITS TERMS. I ALSO UNDERSTAND AND AGREE THAT SUCH TERMS MAY BE AMENDED FROM TIME TO TIME BY THE PRACTICE. (Signature of patient or responsible party if patient is a minor) (Date) (Print name of the patient) ****Notice: If you have a school form that requires a Doctor s signature, there is no charge if the Doctor fills out the form at your appointment. There is a $5.00 charge and a hour processing fee, if the form is completed without an appointment.

3 VACCINATION POLICY UPA and UPA Too are PRO-vaccine providers. Giving children vaccines not only protects the child from preventable disease but it also protects everyone else who may have a compromised immune system. According Centers for Disease Control (CDC) and American Academy of Pediatrics (AAP), it is recommended that children receive the following vaccines at certain intervals: Hepatitis B Diphtheria,tetanus,acellular pertussis (DTaP or TdaP) Diphtheria tetanus (DT or Td) Haemophilus influenza type b (Hib) Pneumococcal conjugate or polysaccharide Inactivated poliovirus (IPV) Measles-mumps-rubella(MMR) Varicella(chickenpox) Influenza(flu) Meningococcal conjugate or polysaccharide Hepatitis A Rotavirus Human papillomavirus Other Why have your child(ren) vaccinated? Vaccines protect your child from diseases which can be fatal or have lasting health consequences Having a high vaccination percentage in a group of children protects children who have immune-deficiencies and those too young to receive vaccines Appropriately vaccinated children also protect adults, especially the elderly, from preventable disease outbreaks Children who are unvaccinated or under vaccinated can spread preventable diseases to all children who are not old enough to be fully immunized. This can happen at the grocery store, the mall, office waiting rooms etc. Please contact your primary care provider to discuss any issues or hesitations you may have with vaccinating your child. If you are not willing to have your child appropriately immunized, consistent the CDC and AAP, we do not feel comfortable being your child's health care provider. If after 30 days of refusal we are unable to convince you of the necessity of vaccinating your child, we respectfully ask you to find another health care provider as declining vaccinations will result in dismissal from the practice. UPA and UPA Too will provide emergent medical care for a month (30 days) after notification to allow you time to look for another provider. By signing this document, you have acknowledged UPA and UPA is a PRO-vaccine practice. Refusal to receive vaccines will result in dismissal from the practice. Patient Name: Legal Guardian s signature: Legal Guardian s name (print) Date:

4 NOTICE OF PRIVACY PRACTICES This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. OUR LEGAL DUTY We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in the Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We are permitted to use and disclose your medical information to those involved in your treatment. Payment: We are permitted to use and disclose your medical information to bill and collect payment for the services provided to you. Health Care Operations: We are permitted to use or disclose your medical information for the purposes of health care operations, which are activities that support this practice and ensure that quality care is delivered. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification or (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use of disclosure of your health information, we will provide you with an opportunity to object to such uses of disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. Required by Law: We may use or disclose your health information for marketing communications without your written authorization. Public Health, Abuse or Neglect, and Health Oversight: We may disclose your medical information for public health activities. Public health activities are mandated by federal, state, or local government for the collection of information about disease, vital statistics (like births and death), or injury by a public health authority. Texas law requires physicians to report child abuse or neglect. Research, Organ Donation, Coroners, Medical Examiners, and Funeral Directors: We may release medical information to organ procurement organizations if you are a donor. We may release your medical information to a coroner or medical examiner to identify a deceased or a cause of death. Further, we may release your medical information to a funeral director where such a disclosure is necessary for the director to carry out his duties. National Security and Law Enforcement Agencies: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmate or patient under certain circumstances.

5 Appointment Reminders: Unless you specify otherwise, in writing, we may use or disclose your health information to provide you with appointment reminders (such as voic messages, , postcards, or letters). PATIENT RIGHTS Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in writing to obtain access to your health information. You may obtain a form to request a copy of your records by contacting our Medical Records office. You may request access to review your records by sending us a letter to the address at the end of this Notice. Federal and Texas State Laws permit us to charge a reasonable cost based fee. Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations, and certain other activities, for the last 6 years, but not before April If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required t agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. {You must make your request in writing} Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. Electronic Notice: If you receive this Notice on our Web site or by electronic mail ( ), you are entitled to receive this Notice in written form. QUESTIONS AND COMPLAINTS If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or the U.S. Department of Health and Human Services. Attention: Address: Privacy Officer 1602 Rock Prairie Road, Suite 340 College Station, Texas Telephone: Fax: (979) (979)

6 UNIVERISTY PEDIATRIC ASSOCIATION Acknowledgement of Review of Notice of Privacy Practices ***You may refuse to sign this acknowledgement*** ***You may request a copy of the Notice of Privacy Practices*** I,, have reviewed/received a copy of UPA and UPA Too Notice of Privacy Practices. Please list all current patients (Parent or Legal Guardian) this acknowledgement applies to: (Print) (Signature) (Date) For Office use ONLY We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but our acknowledgement could not be obtained because: [ ] Individual refused to sign [ ] Communication barriers prohibited obtaining the acknowledgment [ ] An emergency situation prevented us from obtaining acknowledgement [ ] Other (please specify):

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