AUSTIN PEDIATRIC SURGERY PATIENT INFORMATION FORM

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AUSTIN PEDIATRIC SURGERY PATIENT INFORMATION FORM PATIENT NAME RACE: ETHNICITY: FIRST MI LAST STREET ADDRESS: DATE OF BIRTH: / / AGE: CITY: STATE: ZIP: COUNTY: SEX: M F HOME PHONE: ( ) - SCHOOL: SOCIAL SECURITY #: MAILING ADDRESS IF DIFFERENT: REFERRING PHYSICIAN: PHONE ( ) - PRIMARY CARE PHYSICIAN: PHONE: ( ) - RESPONSIBLE PARTY NAME OF PARENT/GUARDIAN ACCOMPANYING CHILD: ADDRESS: CITY: ST: ZIP: COUNTY: SOCIAL SECURITY#: RELATIONSHIP TO PATIENT: DATE OF BIRTH: / / SEX: M F HOME PHONE: ( ) - WORK PHONE: ( ) - MOBILE PHONE: ( ) - EMAIL: OCCUPATION: EMPLOYER: EMPLOYMENT STATUS: BEST WAY TO CONTACT: OTHER PARENT/GUARDIAN: ADDRESS: CITY: ST: ZIP: COUNTY: SOCIAL SECURITY#: RELATIONSHIP TO PATIENT: DATE OF BIRTH: / / SEX: M F HOME PHONE: ( ) - WORK PHONE: ( ) - MOBILE PHONE: ( ) - EMAIL: OCCUPATION: EMPLOYER: EMPLOYMENT STATUS: BEST WAY TO CONTACT: PRIMARY INSURANCE INFORMATION INSURANCE CO. NAME: SUBSCRIBERS NAME: DATE OF BIRTH: / / RELATIONSHIP TO PATIENT: SUBSCRIBERS ID #: GROUP #: GROUP NAME/EMPLOYER: SUBSCRIBERS ADDRESS: CITY/STATE/ZIP SECONDARY INSURANCE INFORMATION INSURANCE CO. NAME: SUBSCRIBERS NAME: DATE OF BIRTH: / / RELATIONSHIP TO PATIENT: SUBBSCRIBERS ID #: GROUP #: GROUP NAME/EMPLOYER: SUBSCRIBERS ADDRESS: CITY/STATE/ZIP PERSON TO NOTIFY IN CASE OF EMERGENCY (OTHER THAN PARENTS) NAME: PHONE: ( ) - RELATIONSHIP TO PATIENT: PHARMACY NAME/LOCATION: PHONE: ( ) - CONSENT TO TREAT I,, HEREBY AUTHORIZE MY CHILD, TO BE EVALUATED AND/OR TREATED BY THE PROVIDERS OF AUSTIN PEDIATRIC SURGERY. PRINT PARENT/GUARDIAN: DATE: / / SIGNATURE PARENT/GUARDIAN: _DATE: / /

Austin Pediatric Surgery Strictly Pediatrics Subspeciality Center 1301 Barbara Jordan Blvd., Suite 400 Austin, TX 78723 Phone (512)708-1234 Fax (512)708-4567 Consent to Treat and Health Care Agreement 1. Consent to Treat I hereby consent to evaluation, diagnostic procedures, testing, and treatment as directed by my physician or his/her designee. I understand that Austin Pediatric Surgery includes teaching facilities and therefore I may be attended to by students and residents of various disciplines and affiliated with various educational programs. I understand that I may request and receive information on the specific affiliation(s) of any particular healthcare provider I encounter during my care. I understand that this Consent to Treat will be valid for each visit I make to the Austin Pediatric Surgery until revoked by me in writing. 2. Consent to Release Information I acknowledge that Austin Pediatric Surgery may release my protected health information as necessary for treatment, payment and health care operations and acknowledge that Austin Pediatric Surgery s Notice of Privacy Practice provides information on how my protected health information may be used and/or disclosed for these purposes. I understand that protected health information pertains to my diagnosis and/or treatment, and includes, but is not limited to, information related to my health history, diagnosis, treatment, prognosis, mental illness (excluding psychotherapy notes), use of alcohol or drugs, prescriptions and laboratory test results, including HIV or the diagnosis of AIDS. I understand that use or disclosure of my protected health information may be necessary before my insurer will pay for the cost of my medical treatment and that if I refuse to consent to this disclosure I may be required to pay the entire cost of medical care provided by Austin Pediatric Surgery. I acknowledge and consent to allow Austin Pediatric Surgery to use health information exchange systems to electronically transmit, receive and/or access my medical information, which may include, but is not limited to, treatments, prescriptions, labs, medical and prescription history and other protected health information. I may opt out and not have my protected health information disclosed through health information exchange systems by providing the signed opt-out form to the practice location where I receive treatment. 3. Assignment of Insurance Benefits/Patient Financial Responsibility I assign and transfer to Austin Pediatric Surgery all rights, title and interest in payments from third-party payors, including but not limited to, health plans and health insurers. I understand that it is my responsibility to know my insurance benefits and whether or not the services I receive are a covered benefit. I understand and agree that I will be responsible for any deductible, co-pay or balance due that Austin Pediatric Surgery is unable to collect from my thirdparty payor for whatever reason. If my account becomes delinquent and it is necessary for the account to be referred to attorneys or collection agencies, or lawsuit filed, I agree to pay all patient charges, reasonable attorneys fees and collection expenses.

4. Medicare/Medicaid/Insurance Benefits If I am eligible for health care benefits under any federal or state program, including, but not limited to Medicare or Medicaid, I certify that the information given by me in applying for payment under any such programs is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or Contractors any information needed for any federal or state program related claims. I request that payment or authorized benefits be made to Austin Pediatric Surgery on my behalf. I understand that I am financially responsible for any deductible, co-pay or balance due under these programs. 5. Lab/X-ray/Diagnostic Services I understand that I may receive a separate bill if my medical care includes lab, x-ray, or diagnostic services that are not provided by Austin Pediatric Surgery or its employees. I also understand that I am financially responsible for any deductible, co-pay or balance due for these services if they are not reimbursed by my third-party payer for whatever reason. 6. Consent to Photograph/Digital Imaging Please note: We do not take pictures at this time I consent to photographs/digital images for treatment, and to verify identity for payment purposes. I understand that the Austin Pediatric Surgery will retain the ownership rights to these photographs/digital images, but that I will be allowed access to view them or obtain copies. 7. Accidental Exposure of Health Care Worker I understand that Texas Law provides and I give consent that in the event a healthcare worker is exposed to my blood or body fluids, my blood may be tested for the HIV antibody and other communicable diseases at no cost to me. 8. Notice of Privacy Practice I acknowledge receipt of the Notice of Privacy Practices from Austin Pediatric Surgery. Patient Printed Name Patient/Responsible Party Signature Witness Patient of Birth

Austin Pediatric Surgery 1301 Barbara Jordan Blvd. Ste 400, Austin, TX 78723 Phone 512.708.1234 Fax 512.708.4567 FINANCIAL POLICY As we enter this doctor-patient (parent) relationship, we agree to provide quality pediatric surgical care at a fair and reasonable price, and you in turn, agree it is your obligation to be prepared to pay at the time of service and to understand the benefits of your insurance. We want to explain our financial policy to you so there are no unpleasant surprises. Co-payments, deductibles and/or coinsurance are due at the time of service. We accept Cash, Personal Check, MasterCard, Visa, Discover and American Express. If you are not prepared to pay the required amount, we may be required to reschedule the appointment. The estimated financial responsibility for scheduled surgery will be due prior to the surgery date. Any remaining balance after your health plan pays will be due upon receipt of a statement. If insurance coverage cannot be verified prior to the appointment, the account will be notated as private pay and payment will be due in full. Account balances over 60 days with no payment activity will be reported to the credit bureau(s). Your insurance policy is a contract between you and your insurance company. Do not assume your policy covers everything or pays at 100%. It is your responsibility to know what your policy covers and what it does not. We cannot quote your benefits. Any item deemed non covered by your insurance carrier will be your financial responsibility. Any disputes about payment must be resolved between you and your insurance company. You are responsible for obtaining a properly dated referral if required by your insurance company and responsible for payment if your claim denies for lack of one. Failure to provide accurate insurance information within 15 days from the date of service will result in the balance becoming your responsibility. If after 60 days from the initial filing date, we do not obtain payment for services performed by your insurance company, the balance will be transferred to you for payment in full. As a courtesy to you, we will file a participating insurance claim for you with proper assignment. Please bring your insurance card with you to every visit. We do not file third party insurance for motor vehicle accidents or liability claims. We do not carry balances for claims to be settled in or out of court. It is the responsibility of the parents to add your newborn to your policy within 30 days from birth. This office is not party to your divorce decree. The financial responsibility rests with the accompanying adult. A $25.00 fee will be assessed for all returned checks. Payments & credits are applied to the oldest charges first, except for insurance payments, which are applied to the corresponding dates of service. Refunds will be provided within 30 days from the date all outstanding claims are satisfied. ASSIGNMENT OF BENEFITS I request payment of the medical and surgical benefits, otherwise payable to me, directly to Austin Pediatric Surgery for services provided by them. I have read and understand the practice s financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice at any time. Responsible Party Printed Name (Must be 18 or over) _ Responsible Party Signature (Must be 18 or over)

Patient History Form Last Name First Name MI of Birth Rev. 4/2013 Mother/Guardian Father/Guardian Primary Care Physician/Pediatrician: How many brother and sisters? Who does the patient live with? Other doctors involved with the patient s care: Has the patient experienced any of the following symptoms listed below? If yes, is the family physician aware of any symptoms/illnesses that you have checked below? Yes SYSTEM NO YES SYSTEM NO YES SYSTEM N YES SYSTEM NO YES O Constitutional Respiratory Musculoskeletal Ear, Nose, & Throat Fever or chills Breathing Difficulties Back pain Loose Teeth Weight Gain/Loss Bronchitis Trauma or Injury Nosebleeds Trouble Sleeping Chronic Cough Neurologic Sore throat/ear pain Gastrointestinal Wheezing Seizures Endocrine/Metabolic Diarrhea Genitourinary Weakness Heat/Cold Intolerance Constipation Pain/difficulty urination Migraines Excessive Sweating Rectal Bleeding Cardiac Eyes Frequent Urination Abdominal Pain Chest pain Glasses/Contacts Excessive Thirst Trouble swallowing Irregular heartbeat Double Vision Hematologic Nausea Skin Blurred Vision Bleeds easily Vomiting Rash/itching Allergy/Immun. Excessive bleeding Psychosocial Bruising Nasal Congestion Other Depressed Mood Lumps Sneezing ADHD PAST HISTORY OF THE PATIENT Has the patient recently or chronically been diagnosed with any of the following? If yes, check any that apply and explain in the space provided. Kidney Disease Yes Cancer Yes Pneumonia Yes Diabetes Yes ADHD Yes Other: Thyroid Disease Yes Asthma Yes Additional comments: Please explain any YES answers in detailed description in the box provided. Birth History: rmal Cesarean Premature; If premature was there Apnea/Irregular Heartbeat Intubation Has the patient ever had any surgery or been hospitalized? If Yes, please list to the right. Yes Surgeries s Hospitalizations other than surgery ****************************************** s Has the patient had any problems with anesthesia? If yes, please list below: Is the patient currently taking any medications or drugs (including over-the-counter, prescription, birth control pills)? No Yes Yes Medication Dose Times Medication Dose Times Does the patient have any allergies (including environmental, medication, food, and reaction to previous blood transfusion)? Yes If yes, please describe: FAMILY HISTORY: Please indicate if parents, brothers and/or sisters have had any of the following conditions: Condition Relation to patient Condition Relation to patient Skin cancer No Yes Diabetes No Yes Stomach Cancer Breast Cancer Kidney problems No Yes Ulcerative Colitis Ovarian Cancer High Blood Pressure Condition Bleeding/Clotting Problems Crohn s Disease Anesthesia reactions Relation to patient Person Completing This Form/Relationship to Patient Reviewed by Provider (s)

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