Healthykidspediatricspw - Combined Patient Paperwork

Patient Information Form
Patient's Name

First NameLast Name
Acct #
Date

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School
Phone #
Please enter a valid phone number.
Home Phone #
Please enter a valid phone number.
Cell Phone #
Please enter a valid phone number.
Parental Status

MarriedSingleWidowedDivorced

Legal Guardian and Emergency Contact

	Parent / Guardian	Parent / Guardian	Other Emergency Contact
Full Name
Home Address
Phone #
Business Phone #
Cell Phone #
Email
Relationship

Please Initial I authorize my physician's office to contact me by using any of the above contact information

Insurance

	Primary	Secondary
Insurance Company
Policy Holder
Relationship
Social Security #
Date of Birth
Policy #
Group #
Effective Date
Employer
Address
Business Phone

Pharmacy

	Local Pharmacy	Mail Away Plan
Name
Address
Phone #
Fax

Configurable list

FINANCIAL POLICY
Upon registration we will need the following information and items: insurance card (if you are a member of one of the plans that we participate with), the name, date of birth, address of the person who is the plan member, government-issued photo ID, address, patient's date of birth, contact phone numbers of both parents and/or all guardians.

Health Insurance: When scheduling each appointment, our team will verify your insurance information with you. Our office staff will verify your eligibility prior to or upon check-in at each appointment. Please make sure that you bring your card to every appointment. If your insurance changes, please notify us a soon as possible.
We participate with many different plans and simply cannot know the provisions of every patient's policy. We do, however, recommend that you make every effort to understand your insurance coverage and if necessary contact your carrier prior to receiving services in order to verify your coverage levels and copay, deductible and coinsurance responsibilities. If you are new to the practice and have an HMO plan., please make sure you have called your plan to select our practice/doctor as your PCP before the day of your visit. Otherwise your child cannot be seen.

Initial

Non-covered Services: Please note that there are some services that your insurance may not cover. These may include important tests which are considered pediatric standards of care such as Vision screens, Hearing screens, Developmental screens and in office lab tests. They may be part of your annual well-child visit. If your insurance rejects the claim for these screens or other services, we will bill you a discounted fee to ensure that you can afford the highest standards of pediatric care. We pride ourselves on providing only the highest quality of care for your child and do this by following American Academy of Pediatrics clinical guidelines and recommendations from other trusted evidence-based resources.

Initial

Balances, Deductibles and Copayments: It is our responsibility, as detailed by the terms of our contracts with health insurance companies that we participate with, to collect copayments at the time of service, and to bill you for any portion of your treatment that your health insurance carrier assigns as your responsibility. It is your responsibility to pay this portion of your bill. We are happy to set up a payment plan with you if you are unable to pay the balance in full at any time. Just make sure to set that up as soon as you receive the bill.

Signature

Returned Checks: If your payment by check is returned by the bank for insufficient funds, you will be required to pay a fee of $50. If more than one check is returned in any given period, we reserve the right to require all future payment via credit card or cash to prevent this situation from recurring.
Missed Appointments: Life happens and we understand that sometimes you cannot make your appointment. Please call us at least 24 hours in advance to cancel or change your appointment. No call to our office equals a "No Show" and if we can't fill your slot, we will need to charge you a $25 fee.

Initial

Self-pay-patients: If you do not have health insurance, payment is required at the time of the visit. If we are out-of-network for your particular insurer, payment is required at the time of visit. Our office can provide a claim form for you to submit to your out-of-network insurer.

Initial

Pending Insurance: If your child has lapsed insurance, no well visit will be scheduled until coverage becomes active. You will be required to pay for each sick visit at your self-pay rate. If you are able to get coverage retroactively, we will submit claims retroactively and refund your self-pay charges after claims are processed minus any copays, deductibles, co-insurance and/or personal responsibility. If your child is a newborn, please see our Newborn Insurance Policy.

Initial

Guarantor: The parent or guardian who signs the patient's paperwork is the party responsible for all charges and payments. Due to confidentiality rules we can only bill the person who signs the practice paperwork. Therefore, if the person responsible for the medical bill changes, the new guarantor must complete a new set of paperwork. Please inform us as soon as circumstances change.

Initial

I have read, fully understand, accept and agree to comply with all of the above policies. I agree to comply with any future amendments to the policies. I consent to the assignment of authorized health insurance benefits by my health insurer to Healthy Kids Pediatrics for any service furnished to my dependent or ward, and understand that failure to make payments timely may result in collection fees.
Patient's Name

First NameLast Name
Parent/Guardian'sSignature

Clear
Date

MonthDayYear
Date
Parent/Guardian's Name(print)

First NameLast Name
Relationship to Patient

OFFICE POLICIES
Our goal is to provide and maintain a good provider-patient relationship. Letting you know about our office policies in advance allows for a good flow of communication and enables us to achieve our goal. Please read each section carefully and initial. Do not hesitate to ask any questions you may have.

Appointments
Schedule an appointment by calling 516-944-8555
Please arrive a few minutes early so that we can verify insurance information. collect paperwork and collect copays.Before making an annual physical appointment, please check with your insurance company as to whether the visit will be covered as a well child visit.

Signature

Patients who arrive on time are seen at their appointment time. Patients who have arrived on time will be seen ahead of those who arrive late. If you arrive late, you may need to wait or have to reschedule your child's appointment.

Signature

Missed Appointments: Life happens and we understand that sometimes you cannot make your appointment. Please call us at least 24 hours to cancel and change appointment. No call to our office equals a "No Show" and if we can'y fill your slot, we will need to charge you a $25 fee.

Signature

Late Arrivals: (>15 minutes and )after scheduler appointment will be offered the next available appointment. We will do all that is possible to accommodate you on the same day.
We strive to minimize any wait time but emergencies do occur and will take priority over a scheduled visit. We appreciate your understanding

Signature

Appointments for additional children should be made by phone prior to coming to the office. An additional $25 charge will applied to add-on appointments. If you would like another child to be seen, please schedule appointments for both children by phone prior to com to the office.
Please note that our schedule does not allow us to schedule three back-to-back well visits for one family in the same day. If all three need to be seen in one day, there needs to be a gap of at least one hour in between the first two visits and the third.

Signature

After-Hours Calls;
Please limit after-hour calls to urgent issues and emergencies. Please call the office during regular office hours for prescription refills, appointment requests and other routine mattes.
When calling in after-hours and leaving a message, please:
Speak slowly and clearly and indicate
Leave a call-back number and disable your call block feature
Follow the doctor's instructions

We are here to provide the best care that we can to your children should the need arise. As always we welcome the opportunity to care for your children and appreciate your trust in the services that we provide.

Signature

Our Vaccine Policy
Healthy Kids Pediatrics does not accept new patients whose parents or caregivers choose not to vaccinate or choose to delay recommended vaccines by more than four months. Parents or caregivers of established patients who choose not to vaccinate or who delay vaccines by more than four months.will be given a one month grave period to find another pediatrics practice. W will not be able to provide families with names of practices accepting unvaccinated or vaccine delayed patients. Healthy Kids Pediatrics strongly recommends vaccination according to the schedule published by the Advisory Committee on Immunization Practice (ACIP). Please recognize that an unvaccinated or vaccine-delayed child is at higher risk of life-threatening illness, disability, and death than vaccinated children. Furthermore, an unvaccinated or vaccine delayed child puts other children at risk, especially those who are too young for vaccination or those who cannot receive vaccinations for various reasons

Signature

Referrals
Three to five days advance notice is needed for all non-emergent referrals. It is your responsibility to know if a selected specialist participates in your plan. Please call the office with with the name of the provider and his NPI or ID number, date of the appointment, reason for appointment and phone and fax number.

Initial

Forms
There is a $20 annual form fee per child. This includes school forms, camp forms, sports forms, etc. Payment is due when the forms are dropped off. We require a minimum 5 day turnaround time.

Initial

Prescription Refills
We require 72 hours' notice for monthly medication refills. Yo may be required to come in for follow-up visits for certain medication refills. Please plan accordingly,

Initial

I have read, fully understand, accept and agree to comply with all of the above policies and accept the responsibility for any payment that becomes due. I agree to comply with any future amendments to office policy.
Patient's Name

First NameLast Name
DOB

MonthDayYear
Date
Parent/Guardian's Signature

Clear
Date

MonthDayYear
Date
Parent/Guardian's name (print)

First NameLast Name
Relationship to patient

PATIENT CONSENT FORM
With my consent, Healthy Kids Pediatrics may use and disclose protected health information (PHI) about me/my child to carry out treatment, payment, and healthcare operations (TPO)/ Please refer to Healthy Kids Pediatrics' Notice of Privacy Practices for a more complete description of such uses and disclosures.

I understand that, under the Health Insurance Portability Accountability of 1996, I have certain rights to privacy in regard to my/my child's PHI. I have received, read, and understand the Notice of Privacy Practice.

Healthy Kids Pediatricsreserves the right to revise its Notice of Privacy Practices at any time. Should I wish to review the revised Notice of Privacy Practice, it may be obtained by forwarding a written request to Healthy Kids Pediatrics at the address above.

With my consent, Healthy Kids Pediatrics may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my/my child's clinical care, including laboratory results among others.

With my consent, Healthy Kids Pediatrics may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.

I have the right to request that Healthy Kids Pediatrics restrict how it uses my/my child's PHY to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to Healthy Kids Pediatrics' use and siclosure of my/my child's PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Healthy Kids Pediatrics has the right to decline to provide treatment to me/my child, other than emergent care, if they choose to.
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Signature

Clear
Date

MonthDayYear
Date

Newborn Financial Policy
Patient Name

First NameLast Name
At your baby's first visit, you will be required to make a $100 Newborn Deposit.

We will check your baby's insurance eligibility before each visit to our office.If your baby is still not covered by insurance beyond 30 days following birth, you will be required to pay $73 per office visit and $125 per well visit that takes place in our office 30 days beyond birth. You will be required to pay these deposits at time of service. Check ups will not be permitted without payment at time of service.

Once your baby's insurance eligibility is established for all past visits and paid for by the insurance company, you will be refunded any deposits, minus any personal responsibility due (ex. deductible, co-insurance, copay).

It is essential that you enroll your newborn on your insurance policy within a few days of birth. This involves contacting your health insurance provider and/or employer as soon as possible and making sure that all the correct information is given.

Please call our office as soon as your newborn becomes active on your insurance policy so that we can submit charges to the insurance company. Until claims are processed and paid, you are still required to pay the above-mentioned deposits.

I understand that I am required to pay a $100 deposit at the first visit, and if insurance eligibility is not established 30 days afte birth, an additional deposit will be due at ech time of service.
Signature

Clear
Date

MonthDayYear
Date

AUTHORIZATION TO RELEASE CONFIDENTIAL HEALTH RECORDS PURSUANT TO HIPPA
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
To Whom it may concern,

I request that a copy of my child's medical records (immunization record, growth chart, recent lab work, specialist reports, and the most recent physical exam) be release and mailed to:

Healthy Kids Pediatrics
211 Main Street
Port Washington, New York 11050
Phone: 516 944-8555
Fax: 516944-0387

As the pson signing this authorization, I understand that I am giving my permission to the above-named health care entity for disclosure of confidential health records. I understand that information disclosed under this authorizatin might be redisclosed by the recipient and this redisclosure may no londer be protected by federal or state law. I also understand that I have the right to revoke this authorization at any time, but that my revocation is not effective until delivered in writing to the person who is in possession of my health records and is not effective as to health records already disclosed under this authorization.
Signature of Individual or Individual's Legal Representative if Individual is a minor or unable to sign:

Clear
Print Name

First NameLast Name
Relationship to individual
Date

MonthDayYear
Date
Previous doctor's name
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Should be Empty:

	Yes	No	Don't Know	Explain
Do you consider your child to be in good health?
Does you child have any serious illnesses or medical conditions?
Has your child had any surgery?
Has your child ever been hospitalized?
Is your child allergic to medicine or drugs?
Do you feel your family has enough to eat?

	Yes	No	Don't Know	Who	Comments
Childhood hearing loss
Nasal allergies
Asthma
Tuberculosis
Heart disease (before 55 years old)
High cholesterol / takes cholesterol medication
Anemia
Bleeding disorder
Dental decay
Cancer (before 55 years old)
Liver disease
Kidney disease
Diabetes (before 55 years old)
Bed-wetting (after 10 years old)
Obesity
Epilepsy / Convulsions
Alcohol abuse
Drug abuse
Mental illness / Depression
Developmental disability
Immune problems, HIV or AIDS
Tobacco use

	Yes	No	Don't Know	Explain
Chickenpox
Frequent ear infections
Problems with ears / hearing
Nasal allergies
Problems with eyes / vision
Asthma, bronchitis, bronchiolitis, or pneumonia
Any heart problem or heart murmur
Anemia or bleeding problem
Blood transfusion
HIV
Organ transplant
Malignancy / Bone marrow transplant
Chemotherapy
Frequent abdominal pain
Constipation requiring doctor visits
Recurrent urinary tract infections and problems
Congenital cataracts / retinoblastoma
Metabolic / Genetic disorders
Cancer
Kidney disease / Urologic malformations
Bed-wetting (after 5 years old)
Sleep problems: snoring
Chronic / recurrent skin problems (ex. acne, eczema)
Frequent headaches
Convulsions or other neurologic problems
Obesity
Diabetes
Thyroid or other endocrine problems
High blood pressure
History of serious injuries / fractures / concussions
Use of alcohol / drugs
Tobacco use
ADHD / anxiety / mood problems / depression
Developmental decay
History of family violence
Sexually transmitted infections
Pregnancy
(For girls) Problems with her periods

	YES	NO	NOT SURE
Does your child live in or regularly visit a building built before 1978 with potential lead exposures, such as peeling or chipping paint, recent or ongoing renovation or remodeling , or high levels of lead in the drinking water?
Has your child spent any time outside the United States in the past year?
Does your child live or play with a child who has an elevated blood lead level?
Does your child have developmental disabilities, put nonfood items in their mouth, or peel or disturb painted surfaces?
Does your child have frequent contact with an adult who may bring home traces of lead from a job or hobby such as: house painting, plumbing, renovation, construction, auto repair, welding, electronics repair, battery recycling, lead smelting, jewelry, stained glass or pottery making, fishing (weights, "sinkers"), firearms, or collecting lead or pewter figurines?
Does your family use traditional medicines, health remedies, cosmetics, powders, spices, or food from other countries?
Does your family cook, store, or serve food in crystal, pewter, or pottery from other countries?
Did your child miss a lead test?New York State requires al children to be tested for lead at age 1 and again at age 2.

Patient Information Form

Initial History Questionnaire

Household

Birth History

Does your child need a lead test?

FINANCIAL POLICY

OFFICE POLICIES

PATIENT CONSENT FORM

Newborn Financial Policy

AUTHORIZATION TO RELEASE CONFIDENTIAL HEALTH RECORDS PURSUANT TO HIPPA