New Patient Registration

NEW PATIENT REGISTRATION

Please answer ALL questions below to the best of your knowledge.
1530 Celebration Boulevard, Suite 301, Celebration, FL 34747

Phone: (407) 566-9700 Fax: (877) 534-5105
Patient Name

First NameLast Name
Suffix
Delivering Physician (NEWBORNS)*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Patient Gender*
Patient Gender Identity*
Patient Sexual Orientation*
Patient Date of Birth*

MonthDayYear
Date
Race

African AmericanAsianNative American/Native AlaskanNative Hawaiian/Pacific IslanderWhiteOther
Ethnicity

Latino/HispanicNot Latino/HispanicOther
Primary Language Spoken

EnglishSpanishVietnamesePortugueseFrenchOther
Date of Evaluation*

MonthDayYear
Date
Mother/Guardian Name*

First NameLast Name
Mother's Date of Birth*

MonthDayYear
Date
Same Address as Patient?

Yes
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone*
Cell Phone*
Email Address*
example@example.com
Employer
Occupation
Father/Guardian's Name*

First NameLast Name
Father's Date of Birth*

MonthDayYear
Date
Same Address as Patient?

Yes
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Email
example@example.com
Employer
Occupation
MEDICAL INSURANCE: Please complete each section to the best of your knowledge.
Name of Insurance*
Effective Date

MonthDayYear
Date
Insurance Phone Number
Policy Holder's Name*

First NameLast Name
Policy Holder's Date of Birth*

MonthDayYear
Date
Member ID Number*
Group Number*
Signature of Person Completing This Form:

Signature*
How did you hear about Celebration Pediatrics?*

SiblingFriend/FamilyHospitalInsurance CompanyWebsiteOb/GynOther
If "other" please specify referral below:
Primary Reason for Appointment?*

NewbornWell-Child/Annual VisitHearingSpeech/LanguageSickOther
Preferred Provider?

Robert "Dr. Bob" Dabrow, MD, FAAPRayyan Anwer, MD, FAAPMonica Urquiola, APRN, FNPVictoria Bernhardt, APRNUndecided
PEDIATRIC PATIENT HISTORY: Please fill out to the best of your knowledge.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Mother's Age at Time of Patient's Birth
Patient's Birth Weight Pounds* Ounces*
Type of Birth

VaginalCesareanEarlyLate
If EARLY, how many weeks early?
If CESAREAN, why?

Patient's Birth History

	Yes	No	Explain
Did mother have any illness/problems with her pregnancy?
Did baby have any problems right after birth?
Was initial feeding Breast Milk?
Was initial feeding Formula?

Before mother knew she was pregnant or any time during her pregnancy, did she?

	Yes	No	Amount	Explain
Smoke Cigarettes
Drink Alcohol
Use "Street" Drugs
Use Prescription Drugs

Patient's CURRENT and PAST History

	Yes	No	Explain
Is your child currently on any medication?
Does your child have any serious or chronic illnesses?
Has your child had serious injuries or accidents?
Has your child had any surgeries?
Has your child ever been hospitalized?
Is your child allergic to any medications?
Does your child have/had asthma, recurrent cough, bronchitis or pneumonia?
Does your child have/ever had nasal allergies or eczema?
Does your child have/ever had frequent ear infections or sore throat?
Does your child have/ever had problems with hearing?
Does your child have/ever had problems with eyes, vision or teeth?
Does your child have/ever had frequent headaches or other neurological problems?
Does your child have/ever had frequent abdominal pain?
Does your child have/ever had constipation requiring doctor's visits?
Does your child have/ever had bladder/kidney problems or bedwetting?
Does your child have/ever had any heart problems/murmur?
Does your child have/ever had anemia or bleeding problems?
Does your child have/ever had thyroid or other gland problems?
Does your child have/ever had diabetes?
Does your child have/ever had ADD/ADHD?
Does your child have/ever had mental health issues?
Does your child use drugs or alcohol?

Please list all those LIVING in the child's HOUSEHOLD

	Name	Relationship to Child	Age
1.
2.
3.
4.
5.

Are there any siblings NOT LISTED ABOVE? If so, please list their FULL name, age and location.

	Name	Age	Location
1.
2.
3.

Child Care Contact Name

First NameLast Name
Child Care Contact Number
Please enter a valid phone number.
Are there any SMOKERS in the HOUSEHOLD?

YESNO
FAMILY MEDICAL HISTORY: Including Parents, Siblings, Grandparents, Aunts and Uncles.

Have ANY family members had the following:

	Yes	No	Who	Comments/Details
Alcohol/Drug Abuse
Allergies
Asthma
Birth Defects
Blood Disorders
Bone Disorders
Cancer
Diabetes
Endocrine Disease
Ear/Nose/Throat Disorders
Heart Disease
High Blood Pressure
High Cholesterol
Immune Disorder
Joint Problems
Kidney Disease
Liver Disease
Migraine Headaches
Metabolic Disorders
Obesity
Seizure Disorder
Skin Disorder
Stroke History
Thyroid Disorders
Lung Disease
Mental Health History
Other Medical History
Other Medical History

Parent/Guardian Signature Signature*
Relationship to Patient

Our Vaccination Philosophy

As healthcare professionals, we believe in the importance of vaccinating all children according to the schedules recommended by the U.S. Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP). These schedules, continuously researched and updated by experts in medicine, immunology, and public health, represent the ideal model for immunization both nationally and globally. The recommended vaccines have been thoroughly studied and proven to be safe and effective in preventing diseases and saving lives. We firmly consider vaccination to be the most crucial intervention we perform.

Addressing Vaccine Controversy

There has always been some level of suspicion and controversy around vaccines. The scientific principles behind vaccination can be challenging for healthcare providers to explain and for parents to grasp. Conflicting information can be overwhelming, and we ask that you trust us as your interpreters of this complex science.

Vaccines are often victims of their own success; they work so well that the diseases they prevent have become rare, which can make the importance of completing the immunization series seem less critical. We understand the difficulty of seeing children endure multiple needle sticks, but extensive research assures us that administering multiple vaccines at once is not overwhelming to the immune system. In fact, our immune systems handle far more challenges daily than what vaccines present. Additionally, there is no evidence linking vaccines to autism or other developmental disabilities. Thimerosal, a mercury-based preservative in a few multi-dose vaccines, has never been shown to be toxic or to cause or exacerbate neurological conditions, including autism. These conclusions are widely accepted in the scientific community and are based on ongoing research.

Risks of Under-Vaccination and Alternative Schedules

Under-vaccination has led to outbreaks of pertussis and measles, both of which can result in hospitalization or death but are preventable with vaccines administered according to the CDC's schedule. Delaying or spacing out vaccines increases the time during which children are vulnerable to infections and necessitates more office visits, which can be traumatic and increase exposure to illnesses.

This issue extends beyond individual health to public health. Delaying or avoiding vaccines endangers other children, including those who cannot be vaccinated for medical reasons and infants too young to be vaccinated

Vaccine Resources

We recognize that deciding to vaccinate can be emotional. We are committed to helping you feel comfortable with following the CDC's vaccine schedules. If you have doubts, please discuss them with our staff or your primary care provider. We recommend the following resources:

- The Panic Virus, a book by Seth Mnookin, an investigative reporter and father.

- CDC: For Parents: Vaccines for Your Children – A useful resource about vaccines designed for parents.

- AAP: Immunization – Information on vaccines and preventable diseases.

- CDC: Recommended Routine Vaccination Schedule: Ages 0-6 & Ages 7-18

- CDC: Vaccine Information Statements (VIS) – Information sheets produced by the CDC

- CHOP: Vaccine Education Center – The Children’s Hospital of Philadelphia’s Vaccine Education Center

Our Vaccination Policy

We, the healthcare providers at Celebration Pediatrics, require adherence to the CDC's vaccination schedule for all children under our care. We will not accept new families who choose not to vaccinate into our practice. Undecided families are welcome, but must commit to the vaccination schedule within two months for newborns. Older children entering our practice without proper immunization will have a one-month grace period after an appointment to discuss vaccines; if they are not vaccinated per the CDC catch-up schedule after this period, we will ask you to find another provider.

Established patients behind on vaccines will also have a one-month grace period to decide on vaccination, followed by adherence to a written plan based on the CDC catch-up schedule. Failure to follow this plan will result in us requesting you find another healthcare provider.

We recommend the annual influenza vaccine, Hepatitis A, Human Papillomavirus (HPV), and both Meningococcal vaccines (MenACWY & Men B) for all age appropriate patients, though refusal of any of the above mentioned vaccines will not lead to discharge from our practice.

If you cannot adhere to our vaccination policy, we ask you to find a healthcare provider who aligns with your views. We do not keep a list of such providers nor recommend any.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Parent / Guardian Name*

First NameLast Name
Parent / Guardian Signature*

Clear
Date

MonthDayYear
Note: This policy does not apply to patients with accepted medical contraindications for specific vaccines.

AUTHORIZATION OR RELEASE OF INFORMATION: For Treatment, Payment or Healthcare Operations.
Parent and/or Guardian's Full Name

First NameLast Name
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
CELEBRATION PEDIATRICS ASSOCIATES, P.A. AUTHORIZATION TO RELEASE OR USE INFORMATION FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS

I (GUARDIAN LISTED ABOVE), hereby authorize the release or use of my dependents individually identifiable health information (PHI "Protected Health Information") and medical record information by Celebration Pediatrics Associates, PA, in order to carry out treatment, payment, or health care operations on behalf (THE PATIENT LISTED ABOVE) Associates, PA Notice of Privacy Practices for a more complete description of the potential release and use of such information. You have the right to review such Notice prior to signing this consent from.
We reserve the right to change the terms of the Notice to Privacy Practices at any time. If we do make changes to the terms, you may obtain a copy of the revised notice.

You retain the right to request that we further restrict how your dependent's PHI is released or used to carry out treatment, payment, or health care operation. Our practice is not required to agree to such requested restriction: however, if we do agree to your requested restriction(s), such restrictions are then binding on the practice.

I acknowledge and agree that the practice may disclose my dependent's PHI and medical record information, confirm or change appointment times and speak to the office on my dependent's behalf with the following individuals who are family members, legal representatives, guardians, healthcare surgeons, or have power of attorney:
Name

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
Any additional individuals can be requested to be added. I agree and have been given notice that the practice may also disclose the following types of information contained in my dependent's medical record to the appropriate authorities as we are required by Florida State Law 384.25

(PLEASE INITIAL ALL CATERGORIES BELOW:)
HIV/AIDS Information:*

Clear
Initials Please
Mental Health Information:*

Clear
Initials Please
Substance Abuse Information:*

Clear
Initials Please
Sexually Transmitted Disease Information:*

Clear
Initials Please
** If the patient is under the age of 18, Pregnancy Information:

Clear
Initials Please
HIV/AIDS Information:   Initial
Mental Health Information:   Initial
Substance Abuse Information:   Initial
Sexually Transmitted Disease Information: Initial
** If the patient is under the age of 18, Pregnancy Information:   Initial
I understand that if the practice needs to contact me, it will be via the primary phone number listed in my guarantor file. I always agree to keep this number updated and understand that my dependent's demographics are my responsibility. I acknowledge that I can update demographics through several sources. I can update them in the office directly, through a call to the office, or through my dependent's patient portal. Should the practice need to communicate with me and my phone is unavailable, after 3 attempts a certified letter will be sent through the mail. I elect for correspondence to be directed to me in the optional form of:
Choose prefer method of contact:

EmailFax
Email
example@example.com
Fax Number
At all times, you retain the right to revoke this consent. Such revocation must be submitted to the practice in writing. The revocation shall be effective to the extent that the practice has already taken action based on the prior consent.

The practice may refuse to treat your dependent if you (or an authorized representative) do not sign this consent form. If you (or an authorized representative) sign this consent and then revoke it, the practice has the right to refuse to provider further treatment to you as of the time of the revocation (except to the extent that the practice is required by law to treat individuals

I have read and understand the information in this consent. I have received a copy of this consent and I am the authorized party to act on the behalf of the patient to sign this document verifying

Parent and/or Guardian's Signature:
Parent and/or Guardian's Signature: Signature*
Please describe your relationship to the patient and include a description of the Representative's authority to act on their behalf:

CELEBRATION PEDIATRICS BILLING AND FINANCIAL POLICY: *Please initial in the space provided and sign your name acknowledging your consent and agreement.
Insurance: If you have insurance, we will provide insurance claim filing for the insurance plans with which we participate; however, if we do not accept your insurance plan or if a claim is denied or a balance is due, you are responsible for payment of the balance owed and we expect payment within 30 days from the date we notify you of such determination. It is your responsibility to pay any co-pay's, deductible, co- insurance or any other balance not paid for by the insurance or third-party payer within 30 days.

It is the responsibility of the patient/guardian to provide us with current insurance plan information prior to services rendered in order for accurate billing of services to be filed. You are also responsible for contacting your insurance company to make sure we are in network with your particular plan. It is important that you are familiar with the guidelines of your plan requirements regarding authorizations, deductibles, co- payments and other vital requirements.

In consideration of services rendered, you agree to transfer and assign to Celebration Pediatrics all rights, title and interest in any payment due to you or otherwise payable to you for services rendered.

Self-Pay: In consideration of the services rendered, you agree to pay Celebration Pediatrics in accordance with the regular rates and terms of service/costs for Celebration Pediatrics. Payment is due in full at the time services are rendered. You affirm that you are duly authorized as the patient or as patient's guardian/agent to execute this document and accept its terms.

Medicare/Medicaid: Patient's certification authorization to release information and payment request. You certify the information given to Celebration Pediatrics in applying for payment under Title XVIII/XIX of the Social security act is correct. You authorize any holder of medical or other information about you to release to Social Security Administration/Division of Family services or its intermediaries or carriers any information needed for this or a related Medicare/Medicaid claim. You further certify all insurance proceeds pertaining to treatment or services provided shall be assigned to Celebration Pediatrics.

Laboratory Charges: We collect and send specimens to a laboratory for processing. We are NOT responsible for laboratory charges. If you have any questions regarding the laboratory charges, you must call the laboratory listed on your bill.

Credit Cards: For your convenience, we will keep your credit card information on file to be used for balances on your account that are your responsibility (co-insurances, co-pays, and deductibles, not to exceed $150.00.

FMLA: There is a $35 fee for FMLA paperwork that is processed withing 7 business days. This fee is due PRIOR to any paperwork being faxed or picked up. There is a $65 fee for expedited FMLA paperwork. There is a $15 fee to update/change your current FMLA paperwork.

Returned Check Fee: A $35.00 fee will be assessed to your account for any returned checks.

No Show Policy: A $25.00 fee will be assessed to your account for any "NO SHOW" or CANCELLATION on a same day SICK appointment. All future appointments require a 24-hour cancellation notice PRIOR to the appointment, or the $25.00 fee will apply.

Tele-Care Call Policy: All calls after normal business hours requesting medical advice will be referred to the Arnold Palmer's Tele-Care Nurse Program. There is a $20.00 fee per call for this service. This fee is YOUR responsibility. This service is NOT covered by any insurance plan.

Colletions/Past Due Accounts: You understand and agree that all accounts must be brought current within 30 days of the service that was rendered. Should your account lapse past the 30 days your account will placed in a collections status and be transferred to our outside collection agency if payment in full or payment arrangements are not made.

You authorize Celebration Pediatrics and hereby give all of its affiliated entities, employees, agents and Independent Contractors permission to call you through the use of dialing equipment artificial voice or similar technology, even if you are charged for the call. You expressly agree that such automated calls may be made by Celebration Pediatrics and all of its ffiliates, contractors and agents. With such consent, you specifically waive any claim you may have against Celebration Pediatrics, its affiliates, contractors and/or agents for making such calls, including any claim under the Telephone Consumer Protection Act. You also expressly agree that this provision applies to the use of text messaging. You authorize Celebration Pediatrics, its affiliates, contractors and/or agents to use any cell phone or other telephone number to contact you for any purpose, including collection of an outstanding invoice at the number set forth below. If you have a change in address or telephone number, it is your responsibility to provide Celebration Pediatrics with your updated contact information.
INSURANCE:*

Clear
Initials Please
SELF-PAY:*

Clear
Initials Please
MEDICARE/MEDICAID:*

Clear
Initials Please
LABRATORY CHARGES:*

Clear
Initials Please
OFFICE CHARGES:*

Clear
Initials Please
COLLECTIONS/PAST DUE ACCOUNTS:*

Clear
Initials Please
INSURANCE:   Initial
SELF-PAY:   Initial
MEDICARE/MEDICAID:   Initial
LABRATORY CHARGES:   Initial
OFFICE CHARGES:   Initial
COLLECTIONS/PAST DUE ACCOUNTS:   Initial
I have read, understand and agree to Celebration Pediatrics' Billing and Financial Policy:
Financial Responsibility Party Full Name*

First NameLast Name
Relation to Patient
Date

MonthDayYear
Date
Signature: Signature*
Telephone Number for Receiving Calls
Please enter a valid phone number.
Telephone Number for Receiving Texts
Please enter a valid phone number.

CELEBRATION PEDIATRICS OFFICE CODING POLICY
An annual exam or well check visit is a routine check-up, which includes obtaining a weight, height, blood pressure check, vision screening and exam by physician. Your provider may also order some screening exams such as lead and hemoglobin, hearing screen, or other studies as indicated.

A problem or "sick" visit focuses on discovering and evaluating problems. Examples could be congestion or cold symptoms, depression, anxiety or a skin condition such as acne.

Each of these visits has their own procedure code which is used to file claims with your insurance company. The insurance company determines their own reimbursement for physician services.

Sometimes during a well exam, a problem is identified based upon a patient's present medical complaint, or when the physician discovers abnormalities during the visit through the exam or review of the patient's history. If this happens, the physician may need to initiate an evaluation of the problem and file a claim for both types of visits on the same day.

Coding rules set by the health insurance industry specifically state: "if an abnormality is encountered or a pre-existing problem is addressed in the process of performing this preventative medicine evaluation service, then the appropriate visit code should also be reported. This is not double billing but is correct coding procedure. This may also save the patient another trip to the office later. Our goal is to address every patient's health concern as thoroughly and efficiently as possible. Sometimes this can be done at the same time as the well exam, thus eliminating the need for an additional visit. However, insurance companies will still require the same co-pays or apply the same deductibles as would be required for a separate visit. (Please keep in mind some conditions may elicit an additional follow-up to address certain conditions or concerns. Your physician will determine this at the time of the visit if indicated.)
Parent and/or Guardian Signature: Signature
Should be Empty:

NEW PATIENT REGISTRATION

1530 Celebration Boulevard, Suite 301, Celebration, FL 34747

MEDICAL INSURANCE: Please complete each section to the best of your knowledge.

PEDIATRIC PATIENT HISTORY: Please fill out to the best of your knowledge.

FAMILY MEDICAL HISTORY: Including Parents, Siblings, Grandparents, Aunts and Uncles.

AUTHORIZATION OR RELEASE OF INFORMATION: For Treatment, Payment or Healthcare Operations.

CELEBRATION PEDIATRICS BILLING AND FINANCIAL POLICY: *Please initial in the space provided and sign your name acknowledging your consent and agreement.

CELEBRATION PEDIATRICS OFFICE CODING POLICY