Pediatric New Patient Packet

New Pediatric Patient Information

This questionnaire will take about 10-20 minutes to complete.
Patient Name (First Middle Last)*
Preferred name
Person completing this form
Birth Date*

MonthDayYear
Date
Social Security Number
Preferred Language
Age
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Address (only complete if different from Mailing Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender
Preferred Pronouns
Legal Gender
Sex assigned at birth
Ethnicity (required by Vaccine program, Medicare, and insurance)

American IndianHispanic/LatinoAsianAfrican AmericanNon-Hispanic/LatinoNative Hawaiian or Pacific IslanderWhiteDecline to specify
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email address
example@example.com
initial here GPC may leave detailed voice messages at my home phone
initial here GPC may leave detailed voice messages at my cell phone
initial here GPC may text message me at my cell phone
initial here GPC may use Spruce to message and text with me
Choose one initial Allow email: GPC may send my personal health information via email. I understand that email may be unencrypted and that this carries risk of a third party gaining access. I also understand that emails may be part of my permanent medical record. I also give permission for GPC to communicate via email with my specialists and other outside providers as indicated through my release of information form.
-OR-
initialDo not allow email: I do not wish to have email initiated from GPC. I understand that if I email GPC they may respond to my request via email.
initial GPC may speak to the person indicated below about my medical condition. This may include information related to mental/behavioral health, substance abuse, sexually transmitted disease, HIV status and reproductive medicine unless specified below field.
Name/Relationship: Name/Relationship
Phone #: Area Code Phone Number
Emergency Contact

NameRelationship
Emergency Contact Address (if different from yours)
Home/Cell Phone Number of Emergency contact
Please enter a valid phone number.
Work Phone Number of Emergency contact
Please enter a valid phone number.
Preferred Pharmacy
Cross streets
Guardianship - If applicable please list who has legal guardianship and their phone number:
Parenting agreement and/or shared custody - please list all legal guardians who may make medical decisions, who need to be informed of medical decisions, and who is legally responsible for medical payments.
With my signature below, I acknowledge and understand that this information will be kept in my medical record according to and the instructions above will be honored until revoked by me in writing. It is my responsibility to notify GPC should I change one or more of the telephone numbers listed above.

Clear
Today's date

MonthDayYear
Date

Greenlake Primary Care Financial Policy

Greenlake Primary Care does not participate with any private insurance which means we will not bill any private insurance on your behalf.

As a patient, you can expect that we will:
- Provide accurate and timely billing.
- Provide your bill to you in paper or electronically (e-statements), depending on your preference.
As a patient or guarantor, this is what we ask of you:
- Payments for incidental services outside of DPC membership are due at the time of service.
- Monthly fees are paid at the first of the month, if credit card is declined we ask that you promptly assist us in updating your credit card.
- If your account falls more than 60 days behind you may be asked to leave our practice.
For your convenience we accept both Visa and Master Card, and ACH payments (through HINT only).

Checks returned for insufficient funds will result in an immediate charge of $35.00 against your account.

We require at least 24-hour notice if you are unable to keep your appointment. Missing an appointment without notice and/or late cancel is considered a no show. Repeated no shows may result in a charge of up to $50.00 ($175 for psychiatric appointments A third no show within 12 months may result in dismissal from the practice.

Questions about your account can be answered by

Naomi Busch, MD (206)524-5656

Credit Card Authorization:

I authorize Greenlake Primary Care to charge my credit on file for both my monthly fee as well as incidental charges. These include charges collected for labs, medications, late fees as above, and other incidentals that will be explained to me prior to any payments being rendered. Credit card numbers and ACH will be entered directly by me or staff into the secure payment system HINT or directly into our online credit card terminal through Transaction Express. No card numbers or bank information is stored in my chart or in the office and the card number, cannot be accessed once entered.
- I can ask and receive a statement of my account which the practice will provide within 5-7 business days.
- Start date of authorization is pursuant to start date of my signed membership agreement.
- The authorization is in effect until rescinded in writing.
I understand that Greenlake Primary Care does not bill insurance, and therefore will not release my information to any health insurance company unless directed by me with written notification.

When patients turn 18 years old, they become the guarantors of their account. They will be asked to review their own financial agreements the first time they have a visit after turning 18.

I have read and understand this policy. A copy will be kept in my chart and a copy may be furnished to me at my request.
Signature

Clear
Today's date

MonthDayYear
Date
Printed name of signer

Household
Please list all those living in the child's home:
1.Name   Relationship   Date of Birth
Health Problems   Occupation
2.Name   Relationship   Date of Birth
   Health Problems   Occupation
3.Name   Relationship   Date of Birth
Health Problems   Occupation
4.Name     Relationship   Date of Birth
Health Problems   Occupation
5. Name   Relationship   Date of Birth
Health Problems   Occupation
6.Name   Relationship   Date of Birth
Health Problems   Occupation
Name and relationship of other important people, such as non-custodial parent:

General Health and Development
Please list any serious illnesses or medical conditions or type "none":
Please list any surgeries or type "none":
Please list any hospitalizations or type "none":
Is your child allergic to any medications or foods? If so what is the reaction? Please type "none" if there are none:
Please list any medications your child takes including dose and frequency:
medication, dose, frequency
medication, dose, frequency
medication, dose, frequency
medication, dose, frequency
Please list any religious or cultural practices that might affect your child's medical care, such as blood transfusions or dietary rules.
Please list any concerns you have about your child's development or type "none":
Please list any concerns you have about your child's behavior or type "none"
At what age did your child:
Sit alone
Walk alone
Say words
Toilet train (daytime)
Age at first menstrual period if applicable
Do you have concerns about your child's diet?   Yes   No
Milk intake now:   cow's milk (whole, 2%, 1%, skim), soy, rice, other
Average cups per day:   #cups

Advanced Consent to Treat Minors

As a general rule, we require the consent of a parent or legal guardian to provide health care services to a minor child (under the age of 18). We understand that there may be times when a parent or guardian is not able to accompany a child to an appointment. However, we cannot provide care to a child who comes to our clinic alone or accompanied by an adult other than a parent or legal guardian if we cannot reach you or don’t have advanced consent to provide treatment.

Signing the Advanced Consent to Treat Minors form below ensures that we can provide care to your child under these circumstances. This signed form will be kept in your child’s medical record. Consent remains in effect until revoked in writing. Any member of our staff can provide the form to revoke consent.

Under Washington State law, minors have the right to consent to certain health care without a parent or guardian’s consent:

If the minor is an emancipated (legally independent) or married to someone at or above age 18.
In the event emergency care is required.
For birth control and pregnancy-related care at any age.
For outpatient drug and alcohol abuse treatment beginning at age 13.
For outpatient mental health treatment beginning at age 13.
For sexually transmitted diseases, including HIV, beginning at age 14.

While we encourage minor patients to involve a parent, guardian or other trusted adult in all aspects of health care, if a minor consents to care as allowed by law, he or she can request confidentiality. That would prohibit us from releasing this information to anyone, including a parent or guardian, without the minor’s express written consent.

If you have questions regarding any of this information, please contact your child’s primary care provider.

I am the parent or legal guardian of this minor and authorize and consent to routine and emergency medical treatment for my child when deemed necessary by qualified medical personnel at Greenlake Primary Care. This authorization will be in effect until revoked in writing by me.
Signature

Clear
Should be Empty:

New Pediatric Patient Information