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Florida Child Neurology
Account#___________
A Division of Florida Pediatric Associates, LLC
PATIENT INFORMATION
Patient Name: __________________________________ DOB: ____/____/____ SS#: _____-_____-______ Sex: Male ___ Female ___
Address: _____________________________ City: ____________________State: _____Zip: __________ Phone#: (____)___________
Race: ☐ African American/Black ☐ American Indian or Alaska Native ☐ Asian ☐ Native Hawaiian or Other Pacific Islander ☐ White
Ethnicity: ☐Hispanic
☐Non-Hispanic
☐Declined
Other family members treated here:________________________________________________________________________________
Primary Care Physician: ________________________________________________________ Phone#: (______) _______-__________
Pharmacy :_____________________________________________________ Pharmacy Phone: (_____) ________-________________
Email:_______________________________________________________________________________________________________
Preferred Method of contact: ☐ Email
☐ Mail ☐ Home Phone
☐ Cell Phone
☐ Text Message
Whom may we thank for referring you:____________________________________________________________________________
PARENT(S) / LEGAL GUARDIAN INFORMATION
Who has legal Custody of the Patient: ( )Parents ( )Mother Only ( ) Father Only ( ) *Foster Parent ( ) Grandparent ( ) *HRS/Other
* APPROPRIATE PAPERWORK MUST BE PRESENTED AT TIME OF VISIT
Mother/Guardian's name: _________________________________________ DOB: _____/_____/______
SS#: _____-_____-______
Address: ☐Check here if same as above
__________________________________________________ City: __________________________State: ______Zip: ____________
Home #: (_____)_______-__________
Cell#: (_____)________-_____________ Work#: (_____)_______-_____________
☐ Check this box if we may use this cell # for text and/or robocall appointment reminders
Occupation:_____________________Employer__________________________ Employer Address______________________________
Father/Guardian's name: ______________________________________________ DOB: _____/_____/_____
SS#: _____-____-_____
Address: ☐Check here if same as above
__________________________________________________ City: ___________________________State: ______Zip: ____________
Occupation:____________________Employer__________________________ Employer Address_______________________________
Home #: (_____)_______-__________
Cell#: (_____)________-_____________ Work#: (_____)_______-_____________
☐ Check this box if we may use this cell # for text and/or robocall appointment reminders
Preferred Language:_________________________________ Preferred method of contact: Email
Phone
Cell Phone
Text
EMERGENCY CONTACTS
#1. Name: ___________________________________ Relationship: ______________________ Phone#: (____) _______-___________
#2. Name: ___________________________________ Relationship: ______________________ Phone#: (____) _______-___________
Feb-14
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INSURANCE INFORMATION
Primary Insurance Carrier: ____________________________________ Policy#______________________________Group#____________
Policyholder’s Name: _____________________________________________________ Date of Birth__________________________
Policyholder’s SS#:: ________________________________________
Relationship to patient: ___________________________________
Claims Address: ______________________________________ City: __________________________State: ______Zip: ___________
Eligibility Phone# (______) _______-____________________
Secondary Insurance Carrier: ______________________________ Policy#______________________________Group#____________
Policyholder’s Name: _________________________________________________ Date of Birth_______________________________
Policyholder’s SS#:: ________________________________________
Relationship to patient: ________________________________
Claims Address: _____________________________________ City: __________________________State: ______Zip: ___________
Eligibility Phone# (______) _______-____________________
ASSIGNMENT OF BENEFITS/ACKNOWLEDGMENTS
I request that payment of authorized insurance benefits be made on my behalf to Florida Pediatric Associates, LLC for any medical services provided to me by that
organization. I authorize the release of any medical or other information necessary to determine these benefits or the benefits payable for related equipment or services
to the organization, the Health Care Financing Administration, my insurance carrier or other medical entity. A copy of this authorization will be sent to the Health Care
Financing Administration, my insurance company or other entity if requested. The original will be kept on file by the organization.
I understand that I am financially responsible to the organization for any charges not covered by health care benefits. It is my responsibility to notify the organization of
any changes in my health care coverage. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible
for the entire bill or balance of the bill as determined by the organization and/or my health care insurer if the submitted claims or any part of them are denied for
payment.
I understand that by signing this form I am accepting responsibility as explained above for all payment for products received.
By signing this document, I also acknowledge that I have received a copy of the organization’s Notice of Privacy Practices. This acknowledgement is required by the
Health Insurance Portability and Accountability Act (HIPAA) to ensure that I have been made aware of my privacy rights.
Parent/Guardian Signature_______________________________________________________Date__________________________________
OFFICE POLICY FOR PAYMENT
Payment is expected IN FULL at the time services are rendered by the patient or the person accompanying the minor child for treatment. If our office is a participating
provider with your insurance carrier, all non-covered services, co-pays, and or deductibles will be collected at the time of each visit. Arrangements for anything other
than full payment at the time of service must be made prior to your appointment. It is the responsibility of the guarantor to understand and accept the guidelines set up
within the individual’s insurance plan. If you are unable to provide us with complete insurance information at the time of your visit you will be responsible for payment
of services IN FULL. I understand that I am financially responsible for any balance not covered by my insurance carrier. I further understand and agree, that if I fail to
make timely payments on my account, I will be responsible for any and all reasonable costs of collection, including filing fees as well as reasonable attorney’s fee.
I have read and understand the office policy for payment and agree to the terms as stated.
Parent/Guardian Signature_______________________________________________________Date__________________________________
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A division of Florida Pediatric Associates, LLC
615 East Princeton Street, Suite 225
Orlando, Florida 32803
Telephone: (407) 897-3544 | Facsimile: (407) 897-4016
Permission to Treat
I, ____________________________ (print name of legal guardian), hereby authorize Florida
Child Neurology, PLLC, and its personnel, to provide medical services, such as medical
examination and treatment, as they deem best for the child’s physical or mental welfare.
_____________________________ _________________ _____________________
(Print child’s name)
(Child’s date of birth)
(Child’s Social Security #)
I authorize the following person/people to bring my child in for treatment and to discuss
any necessary treatments, medications, and to even authorize any tests or labs that are
necessary, up to and including admission to the hospital:
Name:____________________________ Mother:______________________________
Name:____________________________ Father: ______________________________
Name:____________________________ Relationship to patient: _________________
Name:____________________________ Relationship to patient: _________________
**All of the above will provide identification to be placed in the patient’s chart.
I agree that unless I give specific instructions otherwise, medical information regarding
my child’s diagnosis and treatment may be released to biological parents, step parents,
referring physicians and other practitioners, and my insurance company.
I have been advised and understand the Notice of Privacy Practices of Florida Child
Neurology, PLLC.
__________________________________________
Signature of legal guardian
__________________________
Date
Relationship to patient: ___________________________________________________
PATIENT HISTORY FORM
Patient's Name:
DOB:
AGE:
SEX:
----
M
F
Address (Street, City, State, Zip):
Phone Number (Best number to reach parents):
Primary Care Physician Name:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Phone Number for your PCP:
Were you sent here by your OPCP or Oother physician. Name of other physician: - -- - -- - -- - - - - - - - Pharmacy Name:
Pharmacy P h o n e # - - - - - - - - - - -
What is your child's (or your) main reason for the visit:
PAST MEDICAL HISTORY FOR THE PATIENT (circle yes or no when indicated)
Any Past Medical Problems/Diagnosis?: YES NO. If yes, then list all problems.
Past Hospitalizations: YES NO. If yes, then list all hospitalizations and reasons.
Any Past Surgeries?: YES NO. If yes, then list all past surgeries.
Allergies: YES NO. If yes, then please list all allergies.
Smoker?
O Current Smoker O Former Smoker O Never Smoked
Please list all prescription,over-the-counter (ex. Ibuprofen), vitamins or herbal medications and doses:
Medication Name:
Dose:
*Please use reverse side for addt'I space
Please List all prior ADHD or Migraine medications :
Medication Name:
BIRTH HISTORY:
Birth Weight: - - - - - - - -
Birth Length:
Gestational Age: (Weeks)
Type of Delivery: Vaginal
C-Section
Length of stay in nursery
Prematurity: YES_ _ _ NO_ __
If yes how many weeks premature _ __ _
Complications with Pregnancy: YES____ NO_ __ . If yes, then what?
DEVELOPMENT HISTORY: PLEASE INDICATE THE AGE YOUR CHILD;
_ _ 1•t smiled
1•t walked _ _Toilet trained _ _Dressed Independently _ _ Sit alone _ _ Speak single words
Page 1
Patient Name:_ __ __ _ _ _ _ _ _ _ __ __ _ _
DOB:_ _ _ _ __ _ _ __ _ _ __
PRIOR TESTING AND STUDIES PERFORMED:
What past studies has your child (or You) had? When and where were they done: ( CT, EEG, Sleep Study)
...Please use reverse side for addt'I space.
Test Name:
When:
Where:
Use the following symbols (M=mother, F=Father, S=Sibling, MGM, MGF=maternal grandparents,
PGM or PGF=Paternal grandparents , MU or MA=Maternal uncle/Aunt, PU or PA= Paternal uncle/Aunt,
and O=other) to mark any significant family member with a problem/disorder listed below.
Unremarkable
Unknown
FH Aspergers
FH Ataxia
FH Autism
FH Birth Defects
FH Cerebral Palsy
FH Communication Disorder
FH Developmental Delay
FH Genetic Disorder
FH Headaches
FH Macrocephalus
FH Mental Illness
FH Metabolic Disorder
FH Migraines
FH Narcolepsy
FH Neurofibromatosis
FH Seizures
FH Tics
Tourette's
Obsessive Compulsive Disorder
FH Other Medical Problems
SOCIAL HISTORY FOR THE PATIENT
Please list all members living in household (ie mother, father, etc):
List type of pets at home:
Is your child in school/preschool/daycare?
YES NO If yes, please list what grade. -------~~----------
Missed school days because of symptoms? YES NO
School Supports ( Special Ed, Therapy)?
YES I If yes, what type:
Please list any family, social or school stressors currently known:
Please list patient's favorite activities/sports/extra-curricular activities: - - - - - - - - - - -- - - -- - - -- - - - - -
Additional Space for Past Medical, Family Medical and Social History
Page 2
Patient Name:_ _ _ __ _ _ __ _ __ _ _ __ __
DOB: _ __ _ __ _ __ _ _ __
Please Review the following health issues for the patient and mark Yes or No.
YES
NO
General
GI
Overweight
Abdominal pain
Weight Loss
Chronic Constipation
Fever
Alternating constipation/diarrhea
Lethargy/Fatigue
Jaundice
Picky Eater
Nausea
Developmental Delay
Loss of appetite
Reflux
Head and Neck
Swallowing difficulties
Eye changes
Vomiting
Wear glasses
Nasal Congestion
Genitourninary
Sinus Infections
Difficulty urinating
Frequent Colds
Blood in Urine
PE Tubes
Urinary Tract Infections
Tooth Decay
Bedwetting
Mouth Ulcers or Braces
YES
NO
Muscle/Jo ints
Skin
Rashes
Itching
Respiratory
Cough
Asthma/Wheezing
Frequent Bronchitis
Pneumonia
Neurological
Headaches/Migraines
Dizziness
Fainting
Head Trauma
Seizures
Sleep Problems
Speech Problems/Therapy
Tremors
Cardiac
Congenital Problems
Murmur
High Blood Pressure
Fainting
Heart Rhythm Changes
Joint Pain
Joint Swelling
Joint Redness
Sports Injury
Uses Wheelchair
Hematology
Abnormal Bruising
Bleeding
Anemia
Sickle Cell Disease!Trait
Psychiatric
Anxiety
Depression
Developmental Delay
Behavior Problems
Mood Changes
Inpatient Admits
Allergy
Uticaria
Allergic Rash
Eczema
Hay Fever
Recurrent Infections
Seasonal Medications
May explain further for any YES above:
Page 3
A division of Florida Pediatric Associates, LLC
615 East Princeton Street, Suite 225
Orlando, Florida 3280
Telephone: (407) 897-3544 | Facsimile: (407) 897-4016
Acknowledgement of Receipt of Notice of Privacy Practices
I, ________________________, have received the Notice of Privacy Practices from
Florida Child Neurology, PLLC.
_____________________
Signature
_______________________
Date
In lieu of patient or parent/guardian signature, I, _______________________________, a
staff member of Florida Child Neurology, PLLC, state that _________________________ has
been given our current Notice of Privacy Practices.
_____________________
Signature
Patient Name: ______________________
Patient DOB: _________________________
_________________________
Date
A division of Florida Pediatric Associates, LLC
615 E. Princeton Street Suite 225 Orlando FL 32803
Ph: 407-897-3544 Fax: 407-897-4016 Toll Free: 866-356-3075
www.floridachildneurology.com
Fees for Letters, Forms and Medical Records
Patient's Name: _______________________
Patient's DOB:
___/___/___
Florida Child Neurology, PLLC beginning October 6, 2008, will charge the following fees:
1. LETTERS:
A fee of $25.00 will be charged for each official letter provided by our physician and/or provider of
service. (For example a diagnosis letter and/or similar letters.)
2. FORMS:
A fee will be charged for each additional official form completed by our physician and/or provider.
This includes FMLA, SSI, SCHOOL HEALTH, DISABILITY FORMS, DEPT OF MOTOR
VEHICLES and similar forms. The Fee will be $15.00 for a one-page form and $25.00 for a
multiple page form.
3. RECORDS:
The fee for copies of medical records is $1.00 per page up to 25 pages. Each additional page will be
$.25 cents as provided/allowed by the state law. Copy of CD's from EEG studies is $25.00 per
study day.
If the patient/parent/guardian needs a copy of the latest diagnostic test, lab or office visits for continuation of
care/treatment to another physician and/or provider of service. Florida Child Neurology will be happy to assist and
send the records to that provider requested at no charge to the patient. If the patient/parent/guardian would like a copy
of the records that is not directly related to continuity of care; the fees will be applied as stated above.
The requesting party must pay fees in advance along with a release of medical records form. The insurance company
does not cover letter, forms and records copies.
All records, letter and/or forms will be completed within 7-10 business days after payment is received. We will do
everything possible to complete sooner. Documents maybe picked up at our office or mailed. Our staff will call when
the documents are ready to be picked up. An additional fee of $5.00 maybe charged for postage and mailing for large
amount of records.
I acknowledge that I have been notified of these fees and that I understand this policy.
____________________________________
Parent/Guardian/Caregiver Signature
____________________________
Date
____________________________________
Print Name
No-Show Policy Notice
Florida Child Neurology, PLLC reserves the right to discharge patients whose parents/guardians fail to bring them to
appointments without explanation. Cancellation less than 48 hours before the appointment time or arriving more than
10 minutes late also may be considered a no-show. A phone call to the office to explain why you cannot keep the
appointment might prevent a no-show from being recorded against you.
I acknowledge and understand this policy.
____________________________________________
Parent/Guardian/Caregiver Signature
___________________________________________
Print Name
____________________________
Date
Patient Name: ____________________________________
Account #: _____ _______________________
OUR FINANCIAL POLICY Thank you for choosing us as your health care provider. We are committed to the success of your treatment. Please understand that payment of your bill is considered
part of your treatment. The following is a statement of our Financial Policy, which were require you to read prior to any treatment.
All patients must complete our Registration and History forms before seeing the doctor. You must supply us with both your insurance card and driver’s license prior to
your visit.
FULL PAYMENT IS DUE AT THE TIME OF SERVICE. WE ACCEPT CASH, VISA/MASTERCARD, DISCOVER AND AMERICAN EXPRESS. Regarding Insurance Regarding insurance plans where we are a participating provider.; Although we have contracted with your insurance company to provide care to their clients, your
insurance policy is a contract between you and your insurance company. All co-pays and deductibles are due prior to treatment, along with a valid referral from your
primary care provider, if your insurance plan requires it.
Please note that if you require treatment that is not deemed medically necessary or is not a covered service with your insurance carrier, you will be responsible for
payment in full prior to that treatment. In the event that your insurance coverage changes to a plan where we are not participating providers, refer to the paragraph
below.
Regarding insurance plans where we are not a participating provider: You are responsible for payment of your first office visit in full. The balance is your responsibility
whether your insurance company pays or not. We cannot bill your insurance company unless you give us your insurance information. Your insurance policy is a contract
between you and your insurance company. We are not a party to that contract.
If your insurance company has not paid your account in full within 45 days, you will be responsible for payment within 30 days upon receipt of the bill. Please be aware
that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and necessary under the Medicare Program and/or
other medical insurance. You are responsible for these charges. We bill secondary insurance carriers as a courtesy to our patients.
Usual and Customary Charges Our practice is committed to providing the best treatment for our patients. We charge what is usual and customary for our area. You are responsible for payment
regardless of any insurance company’s arbitrary determination of usual and customary rates. You will be responsible for payment if your insurance carrier authorizes and
certifies care but fails to pay as agreed.
Interest We reserve the right to charge interest in the amount of 18 % per year as provided by state law on past due accounts.
Minor Patients The adult accompanying a minor and the parents (or guardians of the minor) are responsible for full payment. For an unaccompanied minor, non-emergency treatment
will be denied unless payment arrangements have been made in advance.
Missed Appointments Unless canceled at least 24 hours in advance, we may charge a fee of $25.00 for missed appointments. This is not covered by insurance. Please help us serve you better by
keeping scheduled appointments.
Returned Checks If your bank returns your unpaid check for any reason, such as insufficient funds or closed account, you will be charged $25.00. Payment must be made prior to your
return to the office and we may not accept any more personal checks.
Billing Questions Please address all billing questions to Florida Pediatric Associates at 727-456-3288 or toll free 866 343-3288.
Collections You may be dismissed from the practice if you fail to meet your financial responsibilities and/or we must use a collection agency to bring your account up-to-date. If it is
necessary to turn the account over to collections and you wish to return to the practice, you will be responsible for all charges, including those incurred to collect the
amount owed, i.e. collections agent’s fees. Your account must be paid in full before you are able to return to the office.
______________________________________________
Signature of Responsible Party
_________________________________________________
Date
______________________________________________
Witness
_________________________________________________
Date