Juan Jose Ferreris, 1vtD. FAAP Mar'.' Helen Perez, 1\'f.0 :: Guide, M.D. FAAP ChnstimMerritt, M.D. FAAP Patient Legal Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _M/F: __ DOB: _ _ _ _ __ Mailing Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _City _ _ _ _ _ _ _ _ _TX 78_ __ Primary Care Physician: _____________ Primary Phone: Pharmacy Phone: Pharmacy Name & Address: Parents/Guardians Information Father's Name: - - - - - - - - - - - - - - - SSN# - - - - - - - DOB: - - - - - - - Father's Cell #: _ _ _ _ _ _ _ _ _ _ _Home #: _ _ _ _ _ _ _ _Other #: _ _ _ _ _ __ Mother's Name: ---------------- SSN# ----------- DOB: --------- Mother's Cell #: Home #: Other #: Guarantor Information Guarantor Name: _ _ _ _ _ _ _ _ _ _TX DL# DOB: ---------- Relationship to patient: SSN#_ _-_ _-__ M/F: _ Phone: _ _ _ _ _ _ _ _ __ Billing Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ City TX 78_ __ Insurance Policy Holder Information Primary Insurance: ___________ 10#: ___________ Grp #: _ _ _ _ __ Policy Holder Name: _ _ _ _ _ _ _ _ _ _ _ _ SSN#: _ _ _ _ _ _ _ _ _ DOB: _ _ _ __ Relationship to Patient: _ _ _ _ _ _ _ _ _ _ _ _ _ Employer: _ _ _ _ _ _ _ _ _ _ __ Policy Holder Address (if different from Patients): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Secondary Insurance: ___________ 10#: ___________ Grp #: _ _ _ _ __ Policy Holder Name: _ _ _ _ _ _ _ _ _ _ _ _ SSN#: _ _ _ _ _ _ _ _ _ DOB: _ _ _ __ Relationship to Patient: _ _ _ _ _ _ _ _ _ _ _ _ _ Employer: _ _ _ _ _ _ _ _ _ _ __ Policy Holder Address (if different from Patients): PAYMENT POLICY (TO BE READ AND SIGNED BY THE RESPONSIBLE PARTY) I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance of my account for any professional services rendered. I have read all of the information on this form and have completed the above answers. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in the above information. I understand and agree that my signature below provides direct assignments of my insurance policy benefits to the doctor for payment of the total charges for professional services rendered. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, attorney or other health care professional involved in my account/treatment. All patients must first stop at the reception desk to satisfy any co-payments prior to seeing the physician. Signature: _____________________ Today's Date: __________ CHILDREN FIRST PEDIATRICS AcknowleclgementF OFm 1 understand that as part of my healthcare, Children First Pediatrics originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as: • A basis for planning my care and treatment • A means ojcommunication among the many health professionals who contribute to my care • A source oJinJormation Jor applying my diagnosis and surgical information to my bill • A means by which a third-party payer can verify that services billed were actually provided • And a tool Jor routine health care operations such as assessing quality and reviewing the competence oj health care proJessionals I understand and have been provided with a Notice of Privacy Practices that provides a more complete description of protected health information uses and disclosures. I understand that I have the right to review the Notice of Privacy Practices prior to signing this acknowledgement. I understand that Children First Pediatrics reserves the right to change its practices and to make the new provisions effective for all protected health information maintained by Children First Pediatrics. I understand that I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that Children First Pediatrics is not required to agree to the restrictions requested. Children First Pediatrics will not use or disclose your health information without your authorization, except as described in the Notice of Privacy Practices. Children First Pediatrics records may contain information created by an entity other than Children First Pediatrics. Children First Pediatrics is not responsible for the information contained therein (including the accuracy, completeness, relevance, legibility or lack thereof of such incorporated records) .. Patient expressly requests release of all records maintained by Children First Pediatrics concerning patient, including incorporated records. Patient acknowledges that Children First Pediatrics has no and assumes no duty to patient regarding the content of or omissions from such incorporated records. Signature of Patient or Legal Representative Date Signed by Patient or Legal Representative Signature of Children First Pediatrics Witness Date Signed by Children First Pediatrics Children First Pediatrics was unable to obtain acknowledgement/consent because: Emergenc}\ C Patient Sedated [J n Patient Confused/Disoriented C Patient Non-Responsive Patient Refused - Reason _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ n (Same date as the Notice of Privacy Practices) Effective Date of the Notice of Privacy Practices CHILDREN FIRST PEDIATRICS PATIENT CONTRACT Insurance: 1.) Provide all insurance information so that we may bill your insurance company, if you do not have your insurance card then we will expect you to pay in full at the time services are rendered. 2.) We will give a 25% discount to patients without insurance when payment is paid in full at the time services are rendered. 3.) Co-Payment is required at the time of service, there is a $25.00 returned check fee. 4.) It is the patients responsibility to verify benefits prior to receiving treatment. 5.) It is the patient's responsibility to verify that a doctor that you are being referred to is a contracted physician on your insurance plan. Appointments: 1.) We DO NOT accept walk-in appointments. 2.) Please call and cancel appointments ahead of time, if you are more than 15 minutes late your appointment may need to be rescheduled. 3.) Due to the limited space for well child exams please try to schedule them at least 2 months in advance. 4.) Inform receptionist of any insurance/address/phone number changes. 5.) Allow at least 2 business days for forms/prescriptions that need to be filled out by physician and/or staff. (PARENT/GUARDIAN SIGNATURE) (DATE) (RECEPTIONIST SIGNATURE) (DATE) 8627 Cinnamon Creek Bldg. 1 San Antonio, Texas 78240 641-KIDS Payment/Eligibility Form I, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ' hereby certify that I am eligible for (name of insured) _________________________________________________________ asof ______~---------------,through (insurance) (effective date) ________________________________ andIhavechosenDL ____________________________________________ (employer name) (primary care physician of child) to be my Primary Care Physician. I understand that if the above is not true or if I am not eligible under the terms of my employer's Medical and Hospital Subscriber Agreement or if charges are incurred that are not covered by my insurance plan, then I am liable for all charges for services rendered. Also, if the above is not true, I agree to pay in full for all services received within 30 days of receiving a bill from my insurance company _______________________________ or the above named physician. Signature of ParentiGuardian ___________________________________________ Date ___________________ Signature of Receptionist ________________________________________________ Date ___________________ 8627 Cinnamon Creek Bldg. 1 San Antonio, Texas 78240 641-KIDS Pediatric History Child's Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Sex: 0 M 0 F DOB: __________________________ BIRTH HISTORY Pregnancy Problems _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ o Alcohol Maternal Use: 0 Cigarettes o Recreation Drug 0 Medications Birth Wt: _ _ _ _ _ _ _ _ _ _ _ Length: _ _ _ _ _ _ _ _ Gestation: _ _ _ _ _ _ _ _ _ _ _ _ __ Delivery: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Nu~eryStay:------------------------------------------------- Neonatal&reen: _____________________________________________________ Developmental Problems: ____________________________________________________ Safety Issues: 0 Car Seat o Guns in Home FAMILY HISTORY o ADD/ADHD/Leaming Problems DAIDS D Allergy Problems o Smoke Alarms o Day Care o Secondary Smoke o Flouride Supplement FAMILY PROFILE o Father NMV\B; o Mother~NI!...A!.LYYl!..:.!e.:....·_·_ _ _ _ _ _ _ _ _ _ _ _ __ o SiblingsN!.!:Mn:..J..!.!...~t,:.....:_ _ _ _ _ _ _ _ _ _ _ __ D Anemia/Blood Problems DAsthma D Birth Defects DCancer D Cardiac Murmurs D Diabetes Mellitus D Hearing Problems D Heart attacks/Stroke <so yrs D High Blood Pressure D High Cholesterol D Lung Disease/TB D Mental Illness D Renal Problems D Seizures D Substance Abuse o Step Family _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ NOTICE OF HEALTH INFORMATION PRACTICES ACKNOWLEDGEMffiNTFORM Children First Pediatrics (Practice Name) The attached notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please sign this cover sheet acknowledging receipt ofthe policy and return it to the receptionist. Review the policy carefully and let us know ifyou have any questions or requests. By my signature below, I acknowledge that I have received the Notice of Health Infonnation Practices of Children First Pediatrics . I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I have provided. I understand that I have the right to request restrictions as to how my health infonnation may be used or disclosed and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. Name of Patient Signature of Patient Date NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES This notice describes how medical information about you may he used and disclosed and how you can get access to this information. Please see the receptionist to request a copy. Understanding Your Health Record/Information • Each time you \i,it a Ill"pital. phY"l'lan or other healthcare provider. a record or vour \ i,it is made, Typically, this record contains vour symptoms, examination and te,t re,ulls, d"'gllC"e" treatment and a plan for future C~lrl' e'r treatment. This infllnl1ation, often referred to as your health or medical record, serves as a: • • • basis for planning your care and treatment means of communication among the man v health professionals who contribute to your care legal document describing the care you received means by which you or a Ihird-pany payer can verify Ihal ,enlces billed II ere actually provided tool in educal11lg health profc"",nal, source of dala f"r medical research source of inf(lnnation I()r public health officials charged with imprl" Ing Ihe health of thc nalion source of data for facility planning and marketing tool with which we can assess and conlinually work to improv'e the care liT render and the outcomes we achieve Understanding what is in your record and hlm your health inf(lnllalion i, ",cd help, vou 10 • ensure Its accural': • better undcC\land II ho, II hat. whl'n, where and why othcr, may acc", vour health infomlation make more intllnlled dec"ion, whcn authorizing d"elosurc to other, • Your Health Information Rights Although your health record is the physil'al properlv of the healthcare practitioner or t'lcility thai compiled it, the infllllllation belongs to you, You have the right to: • • • • • • • request a restriction on certain uses and disclosures of your infonnation as provided by 45 UR IM.522 obtain a paper COPy "I Ihl' nolice of infonnation practiccs upon rcque,t in'pect and (lblain a copy of vour health record as PH" ided I(If in 45 erR 11>4524 amend your hc~lilh rl'Cord as pru\'i,kd in 45 CFR IM,52X obtain an ~lc(uunting ur di:-.do:-.urc:-. of your health infonnation as pi'll\' idcd in 45 CFR IM.52X request C011lmunicailOns 01' your health infllnnation bv altclllatl\c mcal" or al altemative local lon,s • • • Wc rcserve the right to change our practICes and 10 make thc new pro\ isions effectiv'e for all protected Should our health intllrlllC1llon we Illallllaill. intllfllllition practlccs change, Ill' will mail a revised notice 10 Ihl' addre" you hay e supplied us, To Report a Problem If you have questions and would like additional infiJnnatlOll, you may contact the Pri \ aev Officer at thi, onlce, priv'acy of your hcalth S. (" 7, \ iola\cd, you can tile a complaint with thi, onlce or 11lIh the secretary of Health and Human Services, ('here will be no retaliation lilr liling a complaint. Examples of Disclosures for Treatment, Payment and Health Operations Treatment: Inl(lJInalion ublaincd by a nurse, physician or olhn lIlelllbn of vour healthcare team wi II bc reconkd III your record alld used 10 determine the l'Our,C of Irea[melll Illat should work best Illr you, 'luur phYSician \\ ill documenl in your record his or her expectations of Ihe mcmber, oj' your healthcarc team, Members of your heallhcare team will thcn rccord the aclions they In that lIay, [he took and their observations, physician will know how you arc responding 10 treatment. We will also provid~ sub,equent heallhcare providers with copies of \'ariou, reporh Ihal ,hould assist thcm in treating you, Payment: :\ hill mav be ,,'nl lu vou or a third party payer, IhIS 1Il1'l1'1naliun Oil or accompanying the bill may IIll'lulk inl"rl1lallon Ihalldcntifies you, a~ well a:-. YUllr diagllosi~. pnK"l'durl's ano supplies used, Health Opcrtltiom: I, Risk \lanagement - ~ll'mber' ofth~ medical staff or Ihe ri,k ur qllaln) IInpHl\Cment statT may thl' IIlt'l1'1naIIOn 111 your health record to assess the carc dnd UlitCOllll~:-' III your case and uthers like' II rhis int(lrinallon will then be used in an l'i't,"'1 10 C(lnllllUallv improve the qualily and eITe,'tl\l'lll',,, 01 Ihe healthcare and sen icc , mainlain the inti)nnatioll 4, II' you belie\ e your pri\·acy rights hav'e bccn health infllrmalion ncepl 10 [he cxlent thai action has already been lakc'n This organization is required to: 3, Wc will nol usc or d"l'lo,c your health infonnation without your \\rl[ll'n aulhorJ/alioll, except as described in [his 110[1(( rC\"{Jkc your autilori/ation ttl 11~(' or disclose Our Responsibilities pro\idc you 11lIh a 1l0tll'C as to our legal duties and privacy pracllces lIith respect to infllnnatlon Ill' collect and maintain about you abide bv Ihl' [l'llllS ol'this notlcc notify YULl if \\c arc ullable to agree to a rcquesll'd rl'slriclion acco1l1modate reasonable requests you may ha\c to eomlllunicate health inillflnation by allcmative means or at altemativc locatIOns notit~ you of a breach of ·'unsecured" protected health infllflnation \\l' pnl\ Idc. Business ,\ssociates - I here arc some ,en ices provided in our organization Ihrough cuntacts with business associate, I sample, include radiology, laboratory, copy ,crvices, tralhcription services, billingserv Ices, ctc, Whcn these scn'ices arc contracled, we mav di,close your health information lu uur buslllt:ss associate so that they can perillflll X, thc job we hay e askc'd [hcm to do and bill you or vour Ihird-pariV payer fllf services rendered, To prolecl V(lur health infonnation, however, \I e requ irl' Ihe busincss associate to apprupria\clv satcguard ](Iur infllflllation, I\otifkation - We may use or disclose int\l11nalion 10 nolil~' or assist in notifying a family member, personal representali\ c, or another person responsible Illr your care, of your location and general condition, Communication With Family - Health profcssionals, using their be,1 judgment, may disclose to a family member. other relati\e, close personal friend or any olher person you identify, health infonnation relevant to that person's in\ul\ellleni 111 vour care or payment relaled 10 your care, Research - Wc mav d"close infollnation to IT,earcher, whcn Iheir research has been :lppro\ed bv an institutiunal review board that has rc\ Icwed the research proposal and eSlablished proloc(lls I" cnsure the privacy of v uur health int(lnn~III(lll. Funeral Directors - We may disclo,e hcalth infllflnation to funeral directurs consistent with applicable law to carry out their duties, Organ Procurement Organizations Consistent with applicable law, \1 e may disclose health info11l1ation to organ procurement organizations or other enlities engaged in the procurement. banking or Iransplantation or organs tllf the purpose of li"ue donal ion and Iransplant. \\arketing - We may contact you 10 provide appoinlllll'ni rcmindl'r, ur infonllation about treatmenl alle111all\ es or uther health-related bl'llctits and sen icc's Ihal may be of interest tu ~Oll 9, Food and Drug Administration (FDA) We may disclose to the FDA health infllnnation relative to ad\crse cvents \lith respect to fllod, supplemcnls, product and product defects, recalls, repairs or replacement. I() Workers' Compensation - Wc may disclose health infl>nnation to the e~tenl authorized by and to the extent nccessary 10 c011lply wilh laws relating to workers' compensation or olher ,,,nilar l'rugr:l11lS established by law, I I, ruhlit' lIealth \s required by law, we may disclose your health int(lnllation to public hl'alth or legal aUlhorilies charged wilh pr('\ cnting ur contrulling disease. injury or di,abilily, I~, Law Enforcement - We may disclose health infllnnatioll lelr lall cnllm:ement purposes as required bv la\\ (Ir in rcsponse to a valid ,ubpocna, Fedcr:li la \1 makes prov"ion tllr your health infl>nllallllll 10 be rclea,cd 10 an appropriale health oversighl agencv, public health authority or attomey, pro\ ided [hal a \Iork tl)fCe 11lc11lber or business :hsociale b,'li,'\ c, In good faith lhat we have engaged in unlawful conduct or have olherwise violated protessional or clinical standards and are potentially endangering one or more paticnts, workers or the public, This notice is effective as of 11112010 and will remain in effect ulIlil revised,