Corridor Primary Care Pediatrics 601B Leah Avenue San Marcos, TX Phone: (512) Fax: (512)

Transcription

1 Patient Information Corridor Primary Care Pediatrics Phone: (512) Fax: (512) Patient s Name: Age: DOB: Gender: Male Female Race: African-American White/Hispanic Asian Other: Address: Phone: ( ) Street City State Zip Code Parent(s) or Guardian(s) Information Mother s Name Birth Date: Relationship to Patient if other than mother: Home Phone: ( ) Cell Phone: ( ) Address: City: State: Occupation: Social Security # Work Address: Phone: ( ) Marital Status: M W S D Father s Name Birth Date: Relationship to Patient if other than father: Home Phone: ( ) Cell Phone: ( ) Address: City: State: Occupation: Social Security # Work Address: Phone: ( ) Marital Status: M W S D Name(s) of other children Birth date Name(s) of other children Birth date The person(s) listed below have my permission to seek medical attention for my child at Corridor Primary Care Pediatrics. Name HOT Name HOT Name HOT Relationship to child HOT Relationship to child HOT Relationship to child HOT In case of an emergency, please provide the name of a friend or relative at a different address: Phone: ( ) Last Name First Name Cell #: ( ) Address: Relationship to patient: Date Signature Print Name Referred to our office by:

2 Nurse Practitioner Consent Date: Corridor Primary Care Pediatrics Phone: (512) Fax: (512) Patient: Patient DOB: I understand that Corridor Primary Care has Pediatric Nurse Practitioners on staff. Pediatric Nurse practitioners are registered nurses with advanced academic and clinical education in pediatric health care, pharmacology, child development and family dynamics. PNPs provide the following care: Physical exams Diagnose and treat common acute illnesses Provide management and counseling Serve as advocates I understand that I may be offered appointments for sick or well care with a nurse practitioner. I understand that it is my responsibility to know if my appointment is with a physician or a nurse practitioner. I agree to have my child(ren) treated by a nurse practitioner if I schedule an appointment with one. Parent or guardian Date Notice of Privacy Practices I have reviewed this office s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document. Signature of Patient or Personal Representative Date Name of Patient DOB

3 Insurance Information Corridor Primary Care Pediatrics Phone: (512) Fax: (512) Patient: Sex: DOB: Primary Insurance Information: Insurance Company: ID # Group # Effective Date: Employer: Work Phone: Policyholder: Sex: DOB: Policyholder Social Security #: Policyholder Address: City: State: Zip: Home Phone: Secondary Insurance Information: Insurance Company: ID # Group # Effective Date: Employer: Work Phone: Policyholder: Sex: DOB: Policyholder Social Security #: Policyholder Address: City: State: Zip: Home Phone: Date Signature Authorization for Medical Treatment of Minors I authorize Corridor Primary Care Pediatrics to provide medical care to my teenage child (15 years to 18 years) without an accompanying adult. If immunizations are to be given, I agree to be available by phone for a verbal consent Parent/Legal Guardian Relationship Date Parent/Legal Guardian Relationship Date

4 Corridor Primary Care Pediatrics Ph (512) Fax (512) Financial Policy I understand, accept, and acknowledge the following terms: (please initial each line) Payment for all services is my responsibility and is due and payable at the time services are rendered. If my health insurance carrier has accepted Corridor Primary Care (CPC) as a participating provider at the time of service, CPC will submit a claim to my insurance carrier. Claims not paid within a timely manner (60 days) by my insurance company, become fully my responsibility. If my health insurance carrier HAS NOT accepted CPC as a participating provider at the time of service, I am responsible for full payment at the time of service unless prior arrangements have been made with CPC s billing department. Upon my request to CPC s billing department, documentation will be provided so that I may submit a claim for reimbursement of out-of-pocket expenses from my insurance carrier. Any contract for insurance coverage is made between my employer, the insurance company and myself. CPC has no influence over available benefits or the approval of claims. If I wish to use my insurance benefits to cover the cost of any ordered tests, procedures or visits to third party providers it is my responsibility to contact my insurance carrier to verify available benefits as well as participating facilities, providers and specialists. Payment for such services is my responsibility under the terms provided by said individuals. I am responsible for requesting any necessary referrals prior to seeing any specialists, and prior to having any tests or procedures performed. When possible, these requests should be made 5 days prior to the appointment date with the specialist. It is up to the discretion of a CPC provider whether or not to issue a referral requested after the appointment or procedure date. Referrals are not a guarantee of insurance benefits or payment. Concerns regarding denial of payment for ordered tests, procedures or visits to third party providers are to be directed to my insurance carrier. I am responsible for all co-payments and non-covered services at the time of service unless prior arrangements have been made with CPC s billing department. Any co-insurance, deductibles or rejected claims are to be paid in fill to CPC within 30 days of receipt of a bill. Any checks returned unpaid by your financial institution will be subject to a fee of $ You understand if your account is submitted to a collection agency, the fact that you received treatment at our office may become a matter of public record. In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for the child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent s responsibility to collect from the other parent. Overpayments on accounts will be refunded at your request. If no such request is made, the overage will be applied as a credit to your account. If there is a patient due balance elsewhere on the account, the credit will be applied to the balance. You may use this credit for any services provided by our office. Records Release: I hereby authorize the release of information, including medical and billing information, to my referring doctor, insurance company, the responsible party named above, and the immediate family. Assignment of Benefits: I hereby authorize payment of medical benefits to Corridor Primary Care for services rendered to myself and/or dependents. Patient Name: Date of Birth: Date: Signature: Print Name:

5 Patient Initial/Interim History Form Patient s Name Sex Date of birth Patient s Information: Circle any typed answers that apply and write in any answers not typed. Past medical history: shots are up to date Yes or No Birth history: Vaginal /C-Section Was patient born early or late? If so how many weeks Were there any problems with the pregnancy or delivery? Birth wt days in hospital Did they have any jaundice, respiratory, or other problems Have they had pneumonia, frequent ear infections, chicken pox, asthma, seizures, diabetes, urinary tract infections, sickle cell, tuberculosis, mental retardation, heart disease, kidney disease Other List any Hospitalizations List any Surgeries: ear tubes, tonsils removed, adenoids removed, appendix removed. List any Chronic illnesses/problems: asthma, allergies, diabetes, eczema; Speech, motor, or other delayed development Allergies Medications: Name, dose, when is it given and for what, when was last dose Social History: circle those who live in the household currently, give number if more than one Mother (Biological, Step, Foster, Adoptive, Other), Father (Biological, Step, Foster, Adoptive, Other), Sister(s), Step Sister(s), Brother(s), Step Brother(s), Aunt(s), Uncle(s), Cousin(s), Mom s Mom, Mom s Dad, Dad s Mom, Dad s Dad, other adult(s), other children Biological parent are Married/ Live together divorced/ separated If not together what contact does other parent have? weekend, none, shared Circle if your child is exposed to anyone who Smokes, drinks alcohol, or uses drugs? The source of water at your home is from city water line, a well, or bottled Circle any pets in or outside your home: dog, cat, farm animals, reptile, bird, rabbit, rodent, fish, poultry Recent travel: Turn over and finish back side.

6 Family medical history: of blood relatives of the patient Is your child s blood relative history unknown (i.e. they are adopted) circle Otherwise check the boxes under each relative that apply Yes or No Condition Mom Dad Siblings Mat. GM Mat GF Pat GM Pat GF Others If history is unknown check under their name If has died, list cause please Allergies Eczema Asthma Heart problems High blood pressure Heart attacks, at what age? Stroke, at what age? High cholesterol Stomach problems Kidney/bladder problems Vascular problems Skin problems Muscle problems bone problems Neurological problems Seizures Blood disorders Anemia, Sickle cell Cancers, Leukemia Endocrine problems Diabetes, list Type 1 or 2 Thyroid problems Arthritis/Lupus HIV/AIDS Tuberculosis Hepatitis Birth defects Developmental problems Deafness Blindness Obesity ADD/ADHD Depression Bipolar Schizophrenia mental retardation Alcoholism Drug abuse History given by Date M.D.