Patient Information

Assignment and Release
I, the undersigned, certify that I have provided complete and accurate information on behalf of my family. I assign directly to Future Hope Pediatrics all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Future Hope Pediatrics to release all information necessary to secure
payment of benefits. I authorize the use of my signature on all insurance submissions whether manual or electronic.

We, at Future Hope Pediatrics, do our best to complete the financial end of your Child’s medical visit. We will use the information that you, as parents provide us. We ask that you bring your child’s insurance card and co-pay with each visit. If this is not done, you may be asked to reschedule your child’s appointment. You may either pay by cash, check, Visa, MasterCard, AMEX, or Discover. If your check should be returned to the bank, a $25.00 service fee will be charged to your account.
• We will file your primary insurance as a courtesy to you. If they have not responded to our claim within sixty (60) days, the balance is your responsibility.
• All balances on your child’s account are the responsibility of the custodial parent. We will send out a bill to that parent. Other arrangements (i.e. court orders, etc.) are the responsibility of the parents, not our office.
• You are responsible for any amounts not paid by your company including amounts applied to by deductible, non-covered charges, co-pays, and co-insurance.
• Please notify us if your insurance company does not cover immunizations.
• YOUR INSURANCE POLICY IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY. WE ARE NOT PART OF THAT CONTRACT.
• We reserve the right to charge a fee for a no-show Office Visit or Well Child Exam.
• Our office requires a 24 business hour notice to cancel/alter appointments.

IN THE EVENT OF A NON-PAYMENT
• Failure to comply with the above will result in your account being sent to a collection agency. If this should occur, you will be required to pay for future services in cash until the issue is resolved with the collection agency, or we reserve the right to ask you to seek medical attention with another provider.
• Any form of Bankruptcy makes your account cash only.
Each year, we will ask you to update your child’s financial information. This is done in order for us to have the correct information and necessary signatures that are required to file your insurance. It is your responsibility to notify our office of any changes throughout the year. It is the Patient/Responsible Party to know if your insurance company requires a referral for specialists, outpatient testing, or hospital procedures.
PLEASE READ THE BINDERS PROVIDED IN EACH ROOM FOR HIPPA INFORMATION & PATIENT RELATED INFORMATION.

Authorization for Treatment & Verification of Information.
1. I authorize the release of any medical information to process this claim.
2. I authorize payment of medical benefits to Future Hope Pediatrics.
3. I agree to pay for all charges not covered by my insurance.
4. My signature below indicates that I have reviewed all information on this form and the patient information form.
I verify that all information is correct.
5. I have reviewed a copy of the HIPPA policies & reviewed Future Hope Pediatrics policy.
6. I authorize Future Hope Pediatrics to provide medical treatment for my child.

If you would like a copy of this form, please tell the front desk. Thank you.

AAF
At FHP, we strive to provide the best health care to your children and meet your needs as their parents. We are all aware of the many changes that have occurred in the health care industry in recent years. Unfortunately, it has tended to mean that your coverage is not as extensive and yet more expensive. It also means that our reimbursement for routine and sick care has decreased. Services once covered in full are now partially covered with a lower payment, or not covered at all.
Our practice has been hit harder than most because of the way we practice medicine. When practices don’t follow all of the insurance company’s “rules”, the insurance company typically responds by cutting reimbursement on all services. We think
the decisions about health care should be between the patient (and their parents) and the health care provider… not the insurer. We are not willing to compromise great health care in order to meet their requirements.

Many practices have compensated by adding fees for services that were once offered for free— physical forms, medical leave forms, school forms, referrals, after-hours calls, etc. Instead of that, we are instituting a yearly administrative
fee (or AFF) to help offset the costs associated with those services and continue to offer your family excellent care and benefits. The AAF will be due by the first of every year, beginning in January 2020. The fee is $35 per child annually, & non-refundable.

New Patient Fee:
For new patients, in addition to the annual administrative fee, there will be a one-time new patient fee of $100 for each new patient. This initial $135 fee helps to offset the administrative costs that come with establishing a new patient here at Future Hope Pediatrics.  

Well Check Policy:
The best health care is prevention and education. We believe that well-child check-ups give us an opportunity to both know your child and his/her particular needs and help them thrive. Well-baby checks are about way more than “shots”. We are supportive of whatever decision you make for your child in regards to vaccinations, but we do not carry them in our office. For patients who chose to receive a vaccine, we would have you schedule at a local health department, Little Clinic, or vaccine clinic. We
want to be sure your child is growing and developing optimally. And, if there are challenges, we want to address them before they become more difficult. We will never try to coerce you into treatments with which you are not comfortable. But in order to
care for your child, we need to know them. And the best way to do that is regular well-check visits. (Our patients are the healthiest we have ever seen if we wait until your child is sick… You may go years without being seen.)
Therefore, as of January 1st, 2020, well-child checkups will be required. The usual schedule is: 1, 2, 4, 6, 9, 12, 15, 18, 24, and 30 months. From 3 years forward well checks are due at each birthday. You will be asked to schedule your next check-up before leaving the office. If you do not make an appointment, we will make one for you and notify you via text/email of the date and time. It is your responsibility to update contact information as needed.
If you miss a well-check, you will be offered a follow-up appointment. If you choose not to do well checks, we will be happy to provide you with your records so that you can seek care elsewhere.
Most insurers cover preventive (well care) visits themselves without cost to you. Other costs may arise that are not covered by your insurance. That is dependent upon your plan. We do not have access to those particular details.
Well-checks will focus on growth, development, anticipatory guidance, and basic screenings (such as hemoglobin, lead, urine, hearing & vision screens). But preventive care visits do not, by definition, include EVERYTHING you might want to discuss. If concerns arise that go beyond those covered, you may be asked to schedule an additional visit, or you may be billed for a “sick” visit in addition to the well-check. 

Payment due at time of service:
As deductibles have continued to increase, patient responsibility for services has also increased. We reserve the right to charge patient balances to a credit card on file after 3 billing cycles. If unable to do so, your account will be turned over
to collections for resolution. As always, co-pays are required at the time of service.

Phone Calls:
We want to provide you with the best care possible. Our staff is well-trained to answer basic care questions and to advise you on whether or not your child needs to be seen for a sick visit. However, if you require prolonged or repeated conversations, you will need to make an appointment to be seen. Similarly, our providers can briefly answer questions over the phone during office hours. But again, if it is going to be a lengthy conversation, you will need to be seen for a visit in order to accommodate your needs.
After hours our providers are available for emergency calls or questions that CANNOT wait until normal business hours. Routine questions are best answered during office hours or by scheduling an appointment. We will not call out prescriptions or refills after hours because that is detrimental to consistent care. If we feel you need to be seen before our office opens, we will advise you to go to a children’s emergency facility.
We understand that being a parent can be… terrifying. And, we know questions can arise at inconvenient times. But, please keep in mind that after-hours we answer calls from home, while we are caring for our own families. This relationship will work best for all of us with mutual respect and thoughtfulness.
If you have questions about appointments, billing, or to cancel appointments, please call back during office hours.
Messages left on the answering machine will not be reviewed.

Cancellation and No-Show Policy:
In order to meet the needs of our patients for timely well-child appointments and sick visits, our office requires a minimum of 24 hours to cancel/change an appointment. If you cancel/reschedule without 24 hours' notice, or do not keep an appointment, a $25 fee will be charged to your account. We reserve time for your child with each appointment. If you don’t keep that slot, we can’t meet your needs or those of the other children in our practice. If you fail to keep multiple appointments, you will be asked to find another provider for your child.

Late Arrivals:
If you arrive for your appointment late, we may need to reschedule for another day. We set aside time for each appointment. When a patient arrives late, it can affect the rest of the patients on the schedule. If you are delayed, please let us know. We understand that emergencies and unavoidable traffic delays can occur.
If you are 10-15 minutes late, you will likely be asked to reschedule.
If you are 20+ minutes late, you will be charged a no-show fee and rescheduled.

New Patient Fee:

We have instituted a yearly administrative fee (or AFF) to help offset the costs associated with services such as physical forms, medical leave forms, school forms, referrals, after-hours calls, etc. The AAF will be due by the first of every year, beginning in January 2020. The fee is $35 per child annually, & non-refundable.

For new patients, in addition to the annual administrative fee, there will be a one-time new patient fee of $100 for each new patient. This helps to offset the administrative costs that come with establishing a new patient here at Future Hope Pediatrics.  

Parent/Guardian Signature

I, the undersigned, agree to pay the one-time, non-refundable $100 New Patient Fee and the annual $35 administration fee.

I understand and agree to provide my credit card or HSA information at the time of my first appointment.

I authorize this payment to Future Hope Pediatrics. 

*When the new patient packet is submitted and received, and the charges are processed, our office will contact you to schedule your first appointment.

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information that is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI, and other documents or information.
2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in the normal performance of their duties.
5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
6. Your confidential information will not be used for the purposes of marketing or advertising products, goods, or services.
7. We agree to provide patients with access to their records in accordance with state and federal laws.
8. We may change, add, delete, or modify any of these provisions to better serve the needs of both the practice and the patient.
9. You have the right to request restrictions in the use of your protected health information and to request changes in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

 I, the undersigned, do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA Information and Consent Form and any subsequent changes in office policy.   I understand that this consent shall remain in force from this time forward.

Future Hope Pediatrics
231 Midland Park | Shelbyville, KY 40065
Phone: (502) 633-6411 | Fax: (502) 633-6657

Request For Records

I hereby authorize my child/children's PREVIOUS DOCTOR to fax/mail my child/children's health information (protected) to Future Hope Pediatrics.

• I understand that I can revoke this authorization, in writing, at any time by sending written notification to the above-named practice.
  
• I also understand that my revocation is not effective to the extent that the persons I have authorized to use and/or disclose my protected health information have acted in reliance upon this authorization.
• I understand that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by federal laws and regulations regarding the privacy of my child/children's protected health information.
• I have read and understood the above statement and consent to the release of all Medical Records.