Centennial Family Medicine & Wellness PATIENT DEMOGRAPHIC INFORMATION FORM Patient s Full Name (List all name if more than one child)

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1 Centennial Family Medicine & Wellness PATIENT DEMOGRAPHIC INFORMATION FORM Patient s Full Name (List all name if more than one child) Physician: Date of Birth Gender Social Security PARENT/GUARDIAN S NAME: HOME PHONE: DOB: SSN: ADDRESS: CELL PHONE: WORK PHONE: SECONDARY SECONDARY ADDRESS: PRIMARY INSURANCE COVERAGE INSURANCE INSURED S PARENT COMPANY DOB OTHER NAME OF COPAY INSURED AMOUNT INSURED S EMPLOYER INSURANCE CLAIM S INSURANCE ADDRESS PHONE ( ) - CITY STATE ZIP POLICY GROUP INSURED S NUMBER NUMBER SOCIAL SECURITY SECONDARY INSURANCE COVERAGE INSURANCE INSURED S PARENT COMPANY DOB OTHER NAME OF COPAY INSURED AMOUNT INSURED S EMPLOYER INSURANCE CLAIM S INSURANCE ADDRESS PHONE ( ) - CITY STATE ZIP POLICY GROUP INSURED S NUMBER NUMBER SOCIAL SECURITY ANY OTHER YES COMPANY INSURANCE COVERAGE NO NAME PHONE ( ) - WHOM MAY WE THANK FOR PRIMARY CARE REFERRING YOU TO OUR OFFICE? PHYSICIAN INSURANCE AUTHORIZATION AND ASSIGNMENT I authorize Centennial Family Medicine & Wellness to release to my insurance carrier and/or their agents any information necessary to determine benefits payable for related services. I authorize the payment of medical benefits to Centennial Family Medicine & Wellness. I understand that I am ultimately responsible for all services whether covered by insurance or not. I also authorize my physician, based on his/her discretion, to access my chart for utilization management review. DATE: SIGNATURE:

2 CONSENT TO MEDICAL TREATMENT OF A MINOR PARENT or GUARDIAN: Please fill out ONLY in the office visit if for a MINOR. Date: Parent s Name(s): DOB: Name of Person giving consent: Relationship (parent, guardian, managing conservator: Address: Phone Number: To whom it may concern: Alt. Number: I hereby give my permission for Centennial Family Medicine & Wellness to examine and treat my child whose name and age are listed below: Patient s Name who is years of age. In addition, in the event that I cannot be contacted, I hereby give consent to the following individuals or institutions to consent to medical treatment for the foregoing child. Name of Individual(s) and relationship (example: grandparent, babysitter) Name of Institution(s) (example: daycare, school) Consent to Counseling and Provision of Contraception. Texas permits minors to be treated for sexually transmitted diseases and pregnancy without parental consent and as such, I understand that appointments may include discussion, testing, and treatment of sexually transmitted diseases and/or pregnancy issues. Texas does not, however, permit a healthcare provider to counsel and provide contraception to minors without parental consent except under limited circumstances. Check YES or NO as to whether you consent to the counseling and prescription of contraception for the minor whose name appears above. YES, I consent to the counseling and provision or contraception. NO, I do not consent to the counseling and provision or contraception. X Signature of Parent, Guardian, or Managing Conservator Name Relationship Witness to Signature Above: Name Signature Centennial Family Medicine & Wellness-Consent to Medical Treatment of Minor Rev. 06/12

3 CONSENT FOR TREATMENT By signing this consent, I am authorizing my physician and/or other individuals he/she deems appropriate to preform and/or order exams, tests, procedures, and any other care deemed necessary or advisable for the diagnosis and treatment of my medical conditions. This consent is valid for each visit I make to Centennial Family Medicine & Wellness unless revoked by me orally or in writing. Please be informed Texas law allows a patient to be tested for possible exposure to the Human Immunodeficiency Virus (HIV), the virus associated with AIDS, in the following situations: 1)to screen blood, blood products, organs or tissues to determine suitability for donation; 2) if another individual is accidentally exposed to a patient s blood or bodily fluids, such as through a needle stick (any such test shall be conducted pursuant to Centennial Family Medicine and Wellness Clinic infectious disease protocol); or 3) if a medical or surgical procedure is to be performed which could expose health care workers to the patient s blood or bodily fluids. This disclosure is to inform you that you may be tested, at the expense of Centennial Family Medicine and Wellness Clinic if any of those situations occur during your treatment period. Patient s Printed Name Date of Birth Patient/Legal Representative s Signature Today s Date Relationship to Patient Witness Today s Date Centennial Family Medicine & Wellness-Consent for Treatment Rev. 06/12

4 FINANCIAL POLICY Thank you for choosing Centennial Family Medicine & Wellness as your health care provider. We are committed to providing excellent health care services to you, our patient. As a part of our professional relationship, it is important that you have an understanding of our financial policy. All patients must read and sign this form prior to receiving services. It is your responsibility to provide us with your most current insurance information. If you fail to provide accurate insurance information in a timely manner, your insurance company may deny the claim. If the claim is denied, you will be financially responsible for services rendered. We must emphasize that, as medical providers, our relationship is with you, the patient, and not your insurance company. Your insurance is a contract between you, your insurance company and possibly your employer. It is your responsibility to know and understand the level of services covered by your insurance company. If you have Medicaid coverage of any kind, you must notify us prior to your visit. This is part of your agreement with Medicaid, and failure to notify us of Medicaid coverage will result in full financial responsibility for services rendered. We may accept assignment of insurance after verification of your coverage. Please be aware that some or perhaps all of the services provided may not be covered in full by you insurance company. You are financially responsible for services not covered by your insurance. Before receiving services, you must verify that we are participating providers for your insurance company. It is also necessary that our primary care physician is listed as your primary care provider with your insurance company, if required by your contract with your insurance company. In the event we are not participating providers or our physician is not listed as your primary care provider with your insurance company, we will file the initial claim as a courtesy. Payment, however, is due in full at the time of service. We charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company s arbitrary determination of usual and customary rates. Copayments, coinsurance and/or deductibles are due at the time of service. We will estimate the amount you owe based on information we received from your insurance company. However, you are responsible for paying the full amount determined by your insurance company once they have paid your claim-regardless of our estimation. It is your responsibility to provide us with your most current billing information. You must provide your most current billing address, all available telephone numbers and any other important contact information. If your address or contact information changes, it is your responsibility to contact us with the updated information. We will send a statement (to the billing address you provide) notifying you of any balances you may owe. If you have any questions or disputes the validity of this balance, it is your responsibility to contact our business office within 30 days after receipt of the initial statement. Payment in full at time of service. Patient balances not paid in full at time of service could be subject to late fees and may be referred to a professional collection agency and/or attorney for further collections activity. You will be responsible to pay all collection costs incurred, including attorney s fee and court costs if applicable. If you are not able to pay the balance due in full, MUST be pre-approved with the clinic s practice manager. Any late fees already incurred on past due balances will be included in any mutually agreed upon arrangements. If you fail to make payments as agreed upon, your account may be referred to a professional collection agency and/or attorney. You will be responsible for all collection costs incurred, including attorney s fees and court costs if applicable. If your account is assigned to a professional collection agency, you will be notified by certified mail that you will no longer be able to receive services from any of the physicians at Centennial Family Medicine and Wellness Clinic. Failure to accept this certified letter (and/or to pick it up at the post office) serves as notice of termination of services. In the event you submit payment by check and the bank returns the check unpaid for any reason, we will add $25.00 to your original balance. In addition, we may seek all additional legal remedies provided to us under Texas law. We may charge you a No Show fee if you fail to cancel or reschedule your appointment at least 24 hours prior your appointment date. Failure to keep your account balance current may require us to cancel or reschedule you appointment. Full payment is due at time of service. We accept cash, checks, and credit cards. I have read and understand this Financial Policy. Signature of Responsible Party Patient Name: Date Patient Date of Birth: EPM Medical Record Number: Centennial Family Medicine & Wellness-Financial Policy Rev. 05/13

5 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES The Notice of Privacy Practices has been made available to me which provides me a more complete description of the uses and disclosures of certain health information. I understand Centennial Family Health & Wellness reserves the right to change their Notice of Privacy Practices and prior to implementation will provide an updated copy on the clinic web-site and in the physician s office. I may request a copy of the updated Notice of Privacy Practices by calling my physician s office or requesting a copy in person at any of my appointments. Patient s Printed Name Date of Birth Patient/Legal Representative s Signature Date Relationship to Patient Witness Date I wish to be contacted in the following manner: Cell/Home Telephone: ( ) - ( ) Ok to leave message with detailed information ( ) Leave message with call-back number only Work Telephone:( ) - ( ) Ok to leave message with detailed information ( ) Leave message with call-back number only The following names are of people I would like to be involved in or have access to my protected health information on a routine basis. I give permission for Centennial Family Medicine & Wellness to share my protected health information with: Name/Relationship Name/Relationship Name/Relationship ( ) - Contact Phone Number ( ) - Contact Phone Number ( ) - Contact Phone Number Centennial Family Medicine & Wellness-Notice of Privacy Practice Sheet Rev. 05/13

6 PEDIATRIC PATIENT INFORMATION WE STRIVE TO KEEP ALL INFORMATION IN CONFIDENCE AND WILL NOT RELEASE WITHOUT SIGNED CONSENT UNLESS REFERRED TO BY ONE OF THE PHYSICIANS IN THE CENTENNIAL FAMILY MEDICINE & WELLNESS OFFICE-PROSPER. CHILDS NAME: DATE: / / LAST FIRST MI DATE OF BIRTH (DOB): / / AGE: GENDER: M / F MOM S NAME/D.O.B.: DAD S NAME/D.O.B.: FREFERRED PHARMACY: NAME PH. NUMBER PREVIOUS PHYSICAN: NAME PH. NUMBER BIRTH HISTORY ILLNESSES/COMPLICATIONS DURING PREGNANCY: SMOKING,ALCOHOL,DRUGS SURING PREGNANCY: Y / N TYPE OF DELIVERY (please check from list) o Vaginal Delivery o Vaginal Delivery with Vacuum (reason: ) o Vaginal Delivery with Forceps (reason: ) o C-section (reason: ) DELIVERY WAS HOURS LONG. PREGNANCY WAS WEEKS LONG. BIRTH WEIGHT: BIRTH LENGTH: PLEASE ANSWER YES OR NO TO THE FOLLOWING QUESTIONS. If the answer is yes, please provide additional information in the space provided. PRENATAL CARE: Y / N ADOPTED: Y / N PASS HEARING TEST: Y / N JAUDICE BABY: Y / N SEPSIS EVALUATION: Y / N INFANT DISTRESS: Y / N OXYGEN REQUIRED: Y / N STAY IN NICU: Y / N BIRTH DEFECTS: Y / N STATE SCREENING CONDUCTED: Y / N MEDICATIONS REQUIRED: Y / N DATE OF DISCHARGE: Y / N BREASTFED/FORMULA/BOTH? IF FORMULA, KIND? ALLERGIES: (Medications, Food, Insects) MEDICATIONS: (Please include vitamins and herbals) MEDICAL CONDITION(S)/SURGERIES/ HOSPITALIZATIONS- Excluding hospitalization at birth. Example: Asthma, Pneumonia: HAD CHICKEN POX? Y / N DATE (or approximate): / / ARE YOU CONCERNED ABOUT YOUR CHILD S WEIGHT? Y / N

7 PEDIATRIC PATIENT INFORMATION CHILD S NAME: DATE: / / LAST FIRST MI FAMILY HISTORY: (Please list medical conditions that run in your family. For example: Brother: Asthma, Dad: diabetes, Aunt: sickle cell, etc ) CONDITION(S) LIVING? DAD: Y / N MOM: Y / N BROTHER(S): Y / N SISTER(S): Y / N GRANDPARENTS: DAD S MOM: Y / N DAD S DAD: Y / N MOM S MOM: Y / N MOM S DAD: Y / N OTHER RELATIVES: SOCIAL HISTORY WHERE AND WHOM DOES PATIENT LIVE WITH: Please include names and ages of siblings. LIVES WITH A SMOKER: Y / N HOME TYPE: house, apartment, condo WATER SOURCE: ALWAYS WEARS HELMET WHEN BIKING/ROLLERBLADING/SKATEBORADING: Y / N FOR CHILDREN, ALWAYS USES CAR SEAT OF BOOSTER SEAT: Y / N FOR TEENS, ALWAYS WEARS SEATBELT: Y / N CARBON MONOXIDE DETECTORS: Y / N SMOKE DETECTORS ON EACH FLOOR OF HOUSEHOLD? Y / N POOL/SPA AT HOME: Y / N ANY PETS IN HOUSEHOLD? Y / N IF YES, WHAT KIND? DEVELOPMENTAL HISTORY (if over 3 months of age) DAYCARE/SCHOOL ATTENDED: GRADE: ANY DEVELOPMENTAL CONCERNS OR DIFFICULTY WITH SCHOOL? Y / N IF YES, SPECIFY: AGE CHILD SAT ALONE: BEGAN CRAWLING: BEGAN WALKING: SAID FIRST WORD: STOPPED NAPPING: TOLIET TRAINED: SLEPT THROUGH THE NIGHT: SPORTS/ACTIVITIES: HOW MANY HOURS A DAY DOES YOUR CHILD SPENDING: STUDY: WATCH T.V.: VIDEO GAMES: PHYSICALLY ACTIVE: IN THE SUN: WORKING: WITH THE FAMILY: WITH FRIENDS: ANY SPORTS RELATED INJURIES? Y / N IF YES, SPECIFY: PLEASE PROVIDE A COPY OF IMMUNIZATION RECORDS TO THE MEDICAL ASSISTANT. Centennial Family Medicine & Wellness-Pediatric Medical History Rev. 05/13

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