WINSTON-SALEM



P A T I E N T I N F O R M A T I O N Today’s Date _______ /_______ /_______Preferred Contact Home Phone Last Name ___________________________________________________________________Work PhoneMobile Phone First Name ___________________________________________________________________MailPreferred Name _____________________________________________________________PortalMiddle Name ________________________________________________________________Usual Provider Byun Dunn Rice WileyDate of Birth _________ /_________ /_________Primary Language Spoken at Home Social Security #_________ /________ /__________English Spanish Other __________________________________________________________________________________________________________RaceAlaskan AddressAsian ________________________________________________ ________ ______________BiracialCity State Zip CodeBlack/African American□ Male □ FemaleNative/American IndianNative Hawaiian/Other Pacific IslanderHome Phone ( ) ___________-_______________White/Caucasian Mobile Phone ( ) ___________-_______________Other _________________________Work Phone ( ) ___________-_______________EthnicityHispanic or LatinoEmail_____________________________________________________________________________Not Hispanic or LatinoHow did you hear about us? Internet Magazine Friend/FamilyUnknown Other _______________________ Communicator Automated Messaging Preferences Health NotificationsEmail Phone Text MessageAppointments Email Phone Text MessageAnnouncementsEmail Phone Text MessageBilling Email Phone Text MessageHow would you like to receive your Patient Care Summary? Paper Copy Sent to Patient Portal P A R E N T (S) / L E G A L G U A R D I A N (S) I N F O R M A T I O NChild Lives With: □ Mother □ Father □ Parents □ Other ________________________________Emergency Contact Name if parent not available ____________________________________________________________________________________Relationship to Child ____________________________________________ Home Phone Number (__________) _________-_____________Mobile Phone Number (__________) _________-_____________________________________________________________________________ ________________________________________________________________ Mother’s Name Father’s Name _______ /_______ /_______ _______ /______ /_________ _______ /_______ /______________ /______ /________ Date of Birth Social Security # Date of Birth Social Security #________________________________________________________________ ________________________________________________________________ Address Address_______________________________________ ________ ______________ _______________________________________ ________ ______________ City State Zip Code City State Zip Code_________________________________________________________________________________________________________________________________ Employer Employer________________________________________________________________ _________________________________________________________________ Occupation OccupationG U A R A N T O R I N F O R M A T I O NMail Billing Statements to: □ Mother’s Address □ Father’s □ Parents at Same Address I authorize my provider’s office to contact me to remind me of my child’s appointments and any other communications. PARENT/LEGAL GUARDIAN SIGNATURE ___________________________________________________________ Date _______ /______ /________ Data Entered By Staff : ____________________Date _______ /______ /________ A U T H O R I Z A T I O N F O R T R E A T M E N TPATIENT FULL NAME_________________________________________________________________________________________________________ PATIENT DATE OF BIRTH_______ /______ /________THE FOLLOWING INDIVIDUALS HAVE MY PERMISSION TO BRING MY CHILD TO PARTICIPATE IN TREATMENT AND FULL CONSULTATION (INCLUDING PHONE CALLS) WITH THE DOCTOR OR ANOTHER WINSTON-SALEM PEDIATRICS EMPLOYEE.NAME ______________________________________________________________________ RELATIONSHIP ______________________________________NAME ______________________________________________________________________ RELATIONSHIP ______________________________________NAME ______________________________________________________________________ RELATIONSHIP ______________________________________NAME ______________________________________________________________________ RELATIONSHIP ______________________________________NAME ______________________________________________________________________ RELATIONSHIP ______________________________________PARENT/LEGAL GUARDIAN SIGNATURE ___________________________________________________________ Date _______ /______ /________ H E A L T H H I S T O R Y Patient Name ______________________________________ Date of Birth _______ /_______ /_______ Male or Female C H I L D ‘ S M E D I C A L P R O B L E M S (Check any problems child has had)_____ ADHD_____ Abdominal Pain_____ Acne_____ Allergies_____ Anemia_____ Anxiety Disorder_____ Asthma_____ Autism_____ Bedwetting_____ Bladder or Kidney Problems_____ Blood Diseases_____ Bronchiolitis_____ Cancer_____ Chicken Pox_____ Chronic ear infections_____ Congenital Anomalies_____ Constipation_____ Depression_____ Developmental Delays_____ Diabetes_____ Difficulty swallowing_____ Ear or Hearing Problems_____ Eczema_____ Head Injury/Concussion_____ Headaches_____ Hearing Problems_____ Heart Problems/Murmurs_____ Learning Problems_____ Meniere’s disease_____ Mental Illness _____ Muscle, Joint, or Bone Problems_____ Nasal polyps_____ Pneumonia_____ Prematurity_____ Seizures/Epilepsy_____ Skin/Problems_____ Thyroid Problems_____ Vision or Eye Problems_____ Other ____________________________Surgeries (circle) Tonsillectomy Adenoidectomy Ear Tubes Appendectomy Other________________________Any Hospitalizations? _____________________________________________________________________________________________________________________F A M I L Y H I S T O R YChild’s ParentsFatherAgeHealth Problems?Yes NoWhat Type?MotherAgeHealth Problems?Yes NoWhat Type?Child’s BrothersNamesAgesGeneral HealthChild’s SistersNamesAgesGeneral HealthCheck any problems that have occurred in your family and what relation to the patient.RelationshipRelationship_____ ADHD ___________________________ High Cholesterol __________________________ Allergies___________________________ Hypertension __________________________ Asthma ___________________________ Learning Problems __________________________ Cancer ___________________________ Migraines __________________________ Depression ___________________________ Other ________________________________________________ Diabetes ___________________________ Seizures__________________________ Eczema ___________________________ Sickle Cell __________________________ Heart Disease ___________________________ Thyroid Diseases_____________________Please list people (adults and children) who live in your home_________________________________________________________________________________________________________________________________________________Birth Weight ___________________ Where was child born? ____________________________________________________________________________Problems? Y N If yes, what were they? _____________________________________________________________________________S O C I A L H I S T O R Y G E N E R A L P E D I A T R I C (circle) –Questions below may not apply to Newborns Diet? Regular Vegeterian Vegan Gluten Free Specific Carbohydrate Cardiac DiabeticCaffeine intake? None Occasional Moderate HeavyExercise level? None OccasionalModerate HeavySporting activities _________________________________________________________________________________________________________________________Parents' marital status? Married Unmarried Separated Divorced WidowedHome situation? Both Parents Mother Father Relatives Adoptive Parents Foster Parents OtherSiblings ______________________________________________________________________________________________________________________________________Childcare? None RelativePrivate Sitter Daycare/PreschoolAnimal exposure?YesNoPassive smoke exposure?YesNoSmoke/CO detectors in home?YesNoSeat belt/car seat used routinely?YesNoSunscreen used routinely?YesNoInsect repellent used routinely?YesNoGuns present in home?YesNoYear in school _______________________School name ________________________________________________________Fluoride status of home water?FluoridatedNon-fluoridated UnknownPool exposure?YesNoBike helmets?YesNoBully/Bullying?YesNoChanges in family/social situation?YesNoResidence in/travel to an area where Ebola virus transmission is active? Yes NoHas had household contact with an Ebola virus disease patient? Yes NoAny Allergies? ___________________________________________________________________________________________________________________________ O F F I C E P O L I C I E S Thank you for entrusting us with the care of your children. Our goal is to provide you quality care in a friendly, comfortable atmosphere in the most timely manner possible. Please read carefully and sign the bottom of the page indicating your understanding and acceptance of our policies and procedures. Please let us know if you have any questions or concerns.A P P O I N T M E N T P O L I C Y We believe your time is as valuable as ours. We do not overbook patients except in cases of emergency and we do our best to stay on schedule. Please assist us in our efforts to stay on time by arriving a few minutes before your scheduled appointment. If you are more than 15 minutes late you may be asked to reschedule your appointment for a later date, or you may be seen as a work-in if the schedule will allow for it.If you are a new patient, please arrive 15 minutes early to allow for time to complete the necessary medical and insurance information. If paperwork was completed prior to appointment, please bring the completed forms as well as your insurance card on the day of the appointment. Our staff is required to keep patient demographic information as up to date as possible. Please understand that we may ask you for any change of insurance company, home address or phone number at every visit. This information helps us to better serve you. It is the parent(s) responsibility to update custody changes and we are required to maintain the Custody Legal Document in the child’s chart. Winston-Salem Pediatrics will not be involved in custody disputes and if any parent(s) hinders us from giving quality care to our patient(s), we have the right to dismiss the entire family. We will care for the children for 30 days after dismissal and records will be forwarded to a new provider.On occasion you may not receive an reminder call, however; please remember, it is the individual's responsibility to keep track of their child’s appointments. If you need to cancel an appointment, please give us 24 hours advance notice so that we may schedule another patient in the time slot reserved for you. If you do not cancel your appointment 24 hours in advance, a $25.00 fee may be charged (except in cases of emergencies) and is payable prior to future visits. After three repeated no-show visits with no prior call to cancel, your family may be dismissed from the practice. F I N A N C I A L P O L I C Y While filing of insurance claims for our patients is a courtesy that we extend, ALL CHARGES ARE YOUR RESPONSILIBLITY FROM THE DATE SERVICE IS RENDERED. We will bill your insurance company if we are a participating provider. If we do not participate with your insurance plan, you will be responsible for the entire cost of the office visit and any procedures performed. PAYMENTAND COPAYS ARE DUE AT THE TIME OF SERVICE. It is the ultimate responsibility of the patient to understand his/her insurance coverage. Our staff cannot call your insurance company at the time of your appointment to obtain information about your benefits. Insurance policies may change and/or insurance company representatives do not always give us correct or consistent information. Your insurance is a contract between you, your employer, and the insurance company. In the events of denials, errors, or non-covered services, the patient is responsible for all services rendered. We will bill your secondary insurance, however, if that insurance company does not respond within 60 days, we will bill you directly and you are responsible for payment.We do realize that there are times when a temporary financial problem may affect payment of your account. Please contact us promptly for assistance so that we may be able to set up a payment agreement with you. In the event we are forced to submit a delinquent account to a collection agency, there will be a $25.00 fee added to your account. We accept cash, checks, and all major credit cards. There is a $ 25.00 charge for a Non Sufficient Funds check. You agree, in order for us to service our account or to collect any amounts you may owe, we may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable. I/We have read this disclosure and agree that this Office may contact me/us as described above.I N S U R A N C E A U T H O R I Z A T I O N P O L I C Y I authorize payment of medical benefits to Winston-Salem Pediatrics.I authorize the release of all medical information to other physicians and consultants in my child’s care if needed and as necessary to process insurance claims, applications, and prescriptions.Payment is required at the time of service unless you have made other arrangements. As a final courtesy, we will wait for payment from your insurance company; however, all applicable co-payments are due on the date of service.H I P A A P O L I C Y A POLICY OF PROTECTED HEALTH RIGHTS AND INFORMATION ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE.I UNDERSTAND THAT AS A HEALTHCARE PROVIDER, MY PHYSICIAN OR THE PRACTICE’S STAFF MAY SHARE MY MEDICAL INFORMATION FOR TREATMENT, BILLING AND HEALTHCARE BUSINESS PURPOSED. I ACKNOWLEDGE THAT I HAVE BEEN GIVEN INFORMATION THAT DESCRIBES HOW MY MEDICAL INFORMATION IS USED. MY SIGNATURE CONSTITUTES MY ACKNOWLEDGEMENT THAT I HAVE BEEN PROVIDED WITH A COPY OF THE HIPAA NOTICE OF PRIVACY PRACTICES.Your signature below forms a binding agreement between Winston-Salem Pediatrics and the Patient who is receiving medical services, or the Responsible Party for minor patients (those patients under 18 years old). The Responsible Party is the individual who is financially responsible for payment of medical bills. By signing below, you agree to accept full financial responsibility as a patient who is receiving medical services, or as the responsible party for minor patients. Your signature verifies that you have read and understand the above the above policies of Winston-Salem Pediatrics, which includes; Appointment Policy, Financial Policy, Insurance Authorization Policy, HIPAA Policy. I received a copy of the HIPAA Policy. I agree to be bound by all the policies’ terms. I also understand and agree that such terms may be amended from time to time by the practice.Responsible Party Signature ______________________________________________________________________ Date ____ /____ /____ ................
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