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  • Patient and Family Information

    • Patient Info 
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    • Father 
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    • Mother 
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    • Parents Marital Status 
    • Custody (skip if both parents have custody) 
    • We must have information for ALL plans, including copies of all ID cards, divorce decrees, and court orders.

    • Medical Insurance 
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    • Additional Medical Insurance (if applicable) 
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    • Additional Medical Insurance (if applicable) 
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    • Stepfather 
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    • Stepmother 
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    • Foster / Guardian / Other 
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    • Siblings (if applicable) 
    • We are able to link charts and contact information for families with multiple children. Please list the siblings you would like associated with this patient.

    • Completed By 
  • Acknowledgement

  • You are hereby notified pursuant to Michigan Law that as a patient of this practice your child may be tested for the presence of HIV or an HIV antibody without your consent if any health professional or other health facility employee sustains a percutaneous membrane open wound exposure to your child's blood or other body fluids. This test is permitted by Michigan Law and is for the protection of your child as well as the protection of the physicians and employees of Muskegon Pediatrics.

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  • Consent for Care in Absence of Parent

  • I, the parent/guardian named below, give permission for these Authorized Persons to bring my child/children, the patients named below, to Muskegon Pediatrics when I am unable to attend.

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  • Authorization to Share Information with Caregivers

    Complete this form to give Muskegon Pediatrics permission to share information about your children with authorized caregivers.
  • I, the parent/guardian named below, authorize the release and/or sharing of information about the Patient named below, with the following persons or entities listed below ("Authorized Caregivers").

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  • Financial Policy

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  • Carequality Consent

  • Muskegon Pediatrics participates with the national Carequality registry. This registry allows hospitals and physicians across the country to exchange information regarding your health, such as current medications, most recent weight, height, blood pressure, and allergies. This exchange of information allows your child to receive better and informed care if he/she would need to visit an emergency room or see another physician.

    If you would NOT like to have this information available, please provide this in writing to Muskegon Pediatrics. 

    I acknowledge that I was given this information.

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  • HIPPA Acknowledgement

  • The Health Insurance Portability and Accountability Act (HIPAA) requires us to give you a notice of our privacy practices and to acknowledge your receipt of the notice.The Notice of Privacy Practices explains how your health information may be used and or disclosed by us. In addition, it explains your rights with regard to your protected health information, as well as our legal responsibilities. You can view the Privacy Practices in one of three manners: we can email you a copy, you can view it on our website, or you may request a paper copy.

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  • Muskegon Pediatrics No-Show Policy

  • Muskegon Pediatrics understands that unexpected things happen which could prevent patients from keeping their appointment with us. With that in mind, we expect parent/guardian/patient to notify our office as soon as they know they cannot keep a scheduled appointment. In the event that they fail to notify us within 2 hours of their appointment (except in circumstances out of your control) they will be assessed a “no-show” appointment. Three “no-shows” per family per 12-month period will result in the family being discharged from our practice.

     

    I acknowledge I was given this information.

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