PATIENT INFORMATION PATIENT FIRST NAME PATIENT LAST NAME D.O.B. SEX LANGUAGE ETHNICITY RACE

Transcription

1 PATIENT INFORMATION PATIENT FIRST NAME PATIENT LAST NAME D.O.B. SEX LANGUAGE ETHNICITY RACE MOTHER S FIRST NAME MOTHER S LAST NAME D.O.B PATIENT LIVE WITH? YES / NO SOCIAL SECURITY NUMBER: _- - Can we send appointment reminders to the primary phone number as a TEXT MESSAGE? YES NO PHONE: Is this a cell phone? YES/NO MOTHER S ADDRESS: CITY: STATE: ZIP CODE: Mother s What is the best way to contact you? FATHER S FIRST NAME FATHER S LAST NAME D.O.B. PATIENT LIVE WITH? YES / NO PHONE: FATHER S ADDRESS: CITY: STATE: ZIP CODE: Father s What is the best way to contact you? LEGAL GUARDIAN OTHER THAN BIOLOGICAL PARENT: **MUST HAVE LEGAL DOCUMENTATION SHOWING GUARDIANSHIP**** FIRST NAME: LAST NAME: D.O.B ADDRESS: CITY: STATE: ZIP CODE: PHONE: RELATIONSHIP: CUSTODY: FULL / TEMPORARY CIRCLE ONE ARE PARENTS DIVORCED OR SEPARATED? YES NO WHO HAS LEGAL CUSTODY? Are there any legal restrictions that would restrict the non-custodial parent from consenting to medical treatment for the child or from obtaining information about the child s medical treatment? YES NO ** If yes, please provide a copy of any legal paperwork that supports this restriction. PRIMARY INSURANCE INFORMATION SECONDARY INSURANCE INFORMATION INSURANCE NAME: INSURANCE NAME: INSURANCE ID #: INSURANCE ID #: POLICY HOLDER NAME: DATE OF BIRTH OF POLICY HOLDER: RELATIONSHIP TO PATIENT: POLICY HOLDER NAME: DATE OF BIRTH OF POLICY HOLDER: RELATIONSHIP TO PATIENT: AUTHORIZATION LIST: THE FOLLOWING LISTED HAVE CONSENT TO BRING MY CHILD/CHILDREN TO NUBY PEDIATRICS TO DISCUSS CARE AND TREATMENT. NAME: RELATIONSHIP TO PT: NAME: EMERGENCY CONTACT OTHER THAN PARENTS: RELATIONSHIP TO PT: NAME: PHONE : RELATIONSHIP TO PT: NAME: PHONE: RELATIONSHIP TO PT:

2 PATIENT INFORMATION *****PLEASE INITIAL EACH SECTION TO CONFIRM UNDERSTANDING OF POLICY***** NO SHOW POLICY IN ORDER TO KEEP UP WITH OUR GROWING PRACTICE WE REQUIRE A 24 HOUR NOTICE TO CANCEL OR RESCHEDULE AN APPOINTMENT. FAILURE TO GIVE 24 HOUR NOTICE WILL BE CONSIDERED A NO-SHOW. SAME DAY CANCELLATIONS WILL ALSO BE CONSIDERED A NO-SHOW. THERE WILL BE A $25 CHARGE ADDED TO YOUR ACCOUNT PER INCIDENT. THE NO-SHOW FEE DOES NOT APPLY TO MEDICAID OR CHIP PATIENTS DUE TO FEDERAL REGULATIONS, IN THIS CASE THE PATIENT AND ANY FAMILY MEMBERS WILL BE DISMISSED FROM THE OFFICE AFTER 2 NO-SHOWS. WE DO ALLOW A 15 MINUTE WINDOW TO ARRIVE TO YOUR APPOINTMENT, AFTER 15 MINUTES YOU WILL BE ASKED TO RESCHEDULE. **NEWBORNS & NEW PATIENTS**: Due to the increased volume and high demand for new patient appointments, we require a 24 hour notice of cancellation of any initial appointments. FAILURE TO DO SO WILL RESULT IN PERMANENT DISMISSAL. A.D.D./ADHD SCHEDULING POLICY BECAUSE OF THE SIGNIFICANT DEMAND FOR ADD/ADHD APPOINTMENTS, WE HAVE DEVELOPED A STRICT SCHEDULING POLICY. IF YOUR CHILD IS SCHEDULED FOR AN ADD/ADHD APPOINTMENT AT NUBY PEDIATRICS AFTER ONE NO SHOW OR SAME DAY CANCELLATION WE WILL NO LONGER BE ABLE TO TREAT YOUR CHILD FOR THIS CONCERN. WE WILL REFER YOUR CHILD AS NEEDED. FINANCIAL IF YOUR CHILD POLICY IS SCHEDULED FOR AN ADD/ADHD APPOINTMENT AT NUBY INITIALS: PEDIATRICS AFTER ALL PROFESSIONAL SERVICES RENDERED ARE CHARGED TO THE PATIENT AND ARE DUE AT THE TIME OF SERVICE, UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN ADVANCE WITH OUR OFFICE. BALANCES THAT REMAIN ON YOUR ACCOUNT MORE THAN 30 DAYS ARE SUBJECT TO FURTHER ADMINISTRATIVE/PROCESSING FEES. BALANCES OVER 90 DAYS ARE SUBJECT TO REPORTING TO A COLLECTION AGENCY AND THE ADDITIONAL COST ASSOCIATED WITH COLLECTION AND OR LEGAL FEES. A SEPARATE POLICY AGREEMENT WILL REQUIRE YOUR SIGNATURE TO ENSURE THE UNDERSTANDING OF OUR BILLING POLICY. INSURANCE POLICY IT IS THE PARENT S RESPONSIBILITY TO PROVIDE THE CORRECT AND CURRENT INSURANCE POLICY(S) PRIOR TO THE CHILD S APPOINTMENT, IF WE ARE UNABLE TO VERIFY INSURANCE COVERAGE AT THE DATE OF SERVICE YOU WILL BE RESPONSIBLE FOR PAYMENT AT THAT TIME AS WE DO NOT BACK BILL CLAIMS. RETURNED CHECK POLICY A $25 FEE WILL BE CHARGED FOR ANY CHECKS RETURNED FOR INSUFFICIENT FUNDS. IMMEDIATE PAYMENT IN CASH OR BY CREDIT/DEBIT CARD WILL BE REQUIRED UPON RECEIPT OF STATEMENT. WE WILL NO LONGER ACCEPT PERSONAL CHECKS FOR PAYMENT. BY SIGNING BELOW I ACKNOWLEDGE THE FOLLOWING: I HAVE RECEIVED A COPY OF THE NOTICE OF PRIVACY PRACTICES. PAYMENT FOR SERVICES ARE REQUIRED AT THE TIME OF THE VISIT, UNLESS ARRANGEMENTS HAVE BEEN MADE PRIOR TO APPOINTMENT. PATIENTS WITH A DEDUCTIBLE TO BE MET WILL BE REQUIRED TO PAY $100 DEPOSIT AT THE TIME OF VISIT. PATIENTS WITH A CO-INSURANCE AMT. DUE WILL BE REQUIRED TO PAY $25 DEPOSIT AT THE TIME OF VISIT. BY SIGNING BELOW YOU AGREE TO OUR PAYMENT POLICY SIGNATURE: RELATIONSHIP: DATE: x

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