PATIENT INFORMATION
A Division of Consultant In Women’s Health
Welcome to Northeast Pediatric Associates, P.A. Please provide the following information so that we may better serve our patients.
Patient Name:
Date of Birth:
Gender ○ Male ○ Female
Home Address including APT#, if any:
City:
Zip Code:
Primary Phone:
Secondary Phone:
Sibling Names:
_________________________________________
Emergency Phone:
Previous Physician(s):
Name:
_____________________________________________________________________________
_________________________________________
_________________________________________
Address:
____________________________________________________________________________
_________________________________________
Phone #:
____________________________________________________________________________
RESPONSIBLE PARTY
Responsible Party is the individual who agrees to accept financial responsibility for the payment of all services performed at Northeast Pediatric
Associates, P.A. This individual may not necessarily be the insurance card holder. Responsible Party must ready and sign below.
Name:
Relationship to Patient:
Address (if different from above):
Email Address:
Primary Phone Number:
Secondary Phone Number:
Social Security Number:
Occupation:
Primary Phone Number:
○Text Message?
TELEPHONE/EMAIL CONTACT AUTHORIZATION
Secondary Phone Number:
○Text
Message?
Email:
In compliance with Federal HIPAA Privacy Regulations, will you authorize Northeast Pediatric Associates, P.A. to leave a detailed message on your answering
machine/voicemail/email that may include appointment reminders, lab and x-ray results, and other private health information protected by privacy rules?
Primary Phone: ○ Yes ○ No
Secondary Phone: ○ Yes ○ No
Email: ○ Yes ○ No
This authorization will remain in effect until changed or terminated by you or another individual/legal entity authorized to do so by court order or
law by submitting a written request to the Northeast Pediatric Associates, P.A. Privacy Manager in person or by mail to: Northeast Pediatric
Associates, P.A., 8606 Village Drive, Suite A, San Antonio, Texas 78217.
○ Mother
PARENT(S) INFORMATION (Please bring a copy of court/legal documentation for custodial/guardianship/protection orders)
○ Step Mother
○ Foster Parent ○ Other
○ Father
○ Step Father
○ Foster Parent ○ Other
_____________
_____________
Name:
Name:
Date of Birth:
Date of Birth:
SSN:
SSN:
Employer:
Employer:
Occupation:
Occupation:
Work Phone:
Work Phone:
A Division of Consultant In Women’s Health
INSURANCE AUTHORIZATION AND ASSIGNMENTS OF BENEFITS
PRIMARY INSURANCE
SECONDARY INSURANCE (IF APPLICABLE)
Subscriber Name
Subscriber Name
Date of Birth
Date of Birth
Subscriber
ID
Group #
Subscriber
ID
Group #
Insurance Co Name
Insurance Co Name
Phone #
Phone #
Claims
Address
Claims Address
Relationship to Patient
Relationship to Patient
I request that payment of authorized Medicaid/Other Insurance company benefits be made either to me or on my behalf to
Northeast Pediatric Associates, P.A., for any services furnished me by that party who accepts assignment/physician. Regulations
pertaining to Medicaid assignment of benefits apply.
I authorize any holder of medical or other information about me to be released to the Social Security Administration and Health Care
Financing Administration or its intermediaries or carrier or any other insurance company any information needed for this release to
Medicaid/Other Insurance company claims.
I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the
claims. If item 12 of the CMS 1500 claim form is completed, my signature authorizes releasing of the information to the insurer or
agency shown. In Medicaid/Other Insurance company assigned cases, the physician or supplier agrees to accept the charge
determination of the Medicaid/Other Insurance company as the full charge, and the patient’s responsible only for the deductible,
coinsurance, and non-covered services. Co-insurance and the deductibles are based upon the charge determination of the
Medicaid/Other Insurance company.
PRINT NAME OF PARENT OR LEGAL GUARDIAN:
DATE
SIGNATURE OF PARENT OR LEGAL GUARDIAN:
A Division of Consultant In Women’s Health
INSURANCE WAIVER AGREEMENT
Please complete this waiver if you have a newborn, have recently enrolled in a new insurance plan, or for any other reason that
might cause any delays or non-payments form your insurance carrier.
PATIENT NAME:
DATE OF BIRTH:
DATE OF SERVICE:
I, _____________________________________________, understand that in the opinion of Northeast Pediatric Associates, P.A., the
(PRINT NAME OF PARENT/LEGAL GUARDIAN)
services that I have requested to be provided to my child/children on the above date of service may not be covered by my insurance
carrier _________________________________________________.
(INSURANCE CARRIER NAME)
REASON FOR THIS WAIVER:
Northeast Pediatric Associates, P.A., is unable to verify coverage due to the following:
□ NEWBORN: Patient has not been added to the policy. (The member has 30 days to add the newborn to the policy.)
□ NEW ENROLLMENT STATUS (NON-NEWBORN): (Policy holder must contact us within 7 – 10 business days to confirm that
the policy is in active status.
□ OTHER ELIGIBILITY ISSUE: ( Please verify below.)
I understand that I am responsible for payment of the services that I request and receive if these services are not covered by my
health plan provisions.
PRINT NAME OF PARENT OR LEGAL GUARDIAN:
DATE:
SIGNATURE OF PARENT OR LEGAL GUARDIAN:
A Division of Consultant In Women’s Health
IMMUNIZATION POLICY
Northeast Pediatric Associates, P.A. is dedicated to providing the highest quality of evidence-based medical care to our patients.
This includes our adherence to the vaccine schedule recommended by national organizations such as the American Academy of
Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the Advisory Committee on Immunization Practices (ACIP).
These well-respected organizations play a major role in setting the standard of care in both pediatrics and infectious disease.
Together, they strive to eradicate or minimize the incidence of serious preventable disease, thereby promoting the healthcare of all
children. National experts routinely analyze research information, monitor the prevalence of vaccine-preventable diseases, and
monitor reported adverse events following vaccine administration. This information is used to create the best vaccine schedule to
protect all children. Be aware, there are vaccines used in other countries that are not licensed in the United States.
Northeast Pediatric Associates, P.A. serves as an advocate for our patients, while making every effort to respect the wishes of our
parents. Should a family member desire to alter the vaccine schedule or withhold recommended vaccines, Northeast Pediatric
Associates, P.A., believes this decision not only puts your child at risk of serious preventable diseases, but also contributes to the
health risk of others.
Please be advised that if you desire an “alternate” vaccine schedule, or if you intend to refuse vaccines, you do so against the advice
of Northeast Pediatric Associates, P.A., the AAP, the AAFP, and the ACIP. Because we believe that this decision puts your child at risk
for vaccine preventable diseases and increases the health risk for others, Northeast Pediatric Associates, P.A. respectfully declines to
accept you into our practice.
Thank you.
________________________________________________
Print Name of Parent or Legal Guardian
________________________________________________
Signature of Parent or Legal Guardian
_____________________________
Date
A Division of Consultant In Women’s Health
CONSENT FOR TREATMENT
(Please read the following carefully before signing)
As the parent or legal guardian of the child, designated above as the patient, I hereby authorized Northeast Pediatric Associates, P.A.
physicians, mid-level practitioners, and/or their medical representative to perform the required medical treatment considered
advisable for the patient. I realize that no guarantees can be made as to the eventual outcome of the medical treatment advised or
performed. However, I may expect the medical treatment advised or performed by Northeast Pediatric Associates, P.A. physicians,
**mid-level practitioners, and/or their medical representative to be reasonably sound by accepted medical standards.
**Mid-level practitioners are either Nurse Practitioners or Physician Assistants, licensed by the state to diagnose and treat illnesses,
injuries, disease or other medical conditions. They typically hold a bachelor’s degree with advanced education in Pediatrics. These
practitioners work hand-in-hand with the patient’s primary care physician, providing preventive care, well child examinations,
physicals, immunizations and developmental screenings. They are able to order further diagnostic tests write prescriptions, or refer
out to a medical specialist. We will do our absolute best to appoint your child(ren) with their primary care physician, however, there
may be an instance where you may have the option (or not) to see the mid-level practitioner.
We ask that a parent or guardian be present for your child(ren)’s initial appointment. We must be able to obtain pertinent family
background and medical history that is necessary for the treatment of your child(ren). It is the policy of Northeast Pediatric
Associates, P.A. that you must authorize family members and others who make appointments and accompany your child(ren) to
their appointments. Therefore, the following other individuals (other than parents) are authorized to act in your place with respect
to any and all medical matters after your initial appointment with us. Please note that as we have no control over these individuals,
any private health information disclosed under this authorization is no longer protected by the Privacy Rule.
PARENTAL CONSENT IN CASES OF DIVORCE
(If you have a court order, please present us with a copy for your child(ren)’s file)
According to Texas Statutes – Family Code §153.073 (a), unless limited by a court order, a parent appointed as a “conservator”
(managing or possessory) of a child has at all times the following rights:




Right of access to medical, dental, psychological, and education records of the child
Right to consult with a physician, dentist, or psychologist of the child
Right to be designate on the child’s records as a person to be notified in case of an emergency
Right to consent to medical, dental, and surgical treatment during an emergency involving an immediate danger to the
health and safety of the child.
Name
Phone No.
Relationship
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
_______________________________________
Print Name of Parent or Legal Guardian
____________________
Date
__________________________________________
Signature of Parent or Legal Guardian
A Division of Consultant In Women’s Health
FINANCIAL POLICY
It is the policy of this office to help keep health care costs as low as possible. In order to do this, we need to keep our billing costs to a minimum.
Your initial by each item indicates your understanding and agreement.
Please assist our office in the following ways:

Bring your child’s current health insurance card to every office visit.

Notify us of any changes in demographics information (i.e. insurance, address, phone number, etc.)

Pay your co-pay or deductible at the time of service; or if you do not have insurance, please come prepared to pay for your visit in full.

Double check with your plan as to the participation status of Northeast Pediatric Associates, P.A. (A Division of Consultant in Women’s Health)
Please understand you are responsible for verifying this information with your carrier.

Verify coverage limitations prior to appointment date.
Monthly Statements: If you have a balance on your account, we will send you a monthly statement. Unless other arrangements are approved by
us, the balance on your account is due and payable within 14 days of the statement date. If you are unable to pay the amount due or if you
disagree with the billed amount, contact our billing department immediately. Any outstanding account balance greater than 30 days will be
charged a$15 statement fee. (______) **Thoughts on the statement fee for any balance over 30 days?.**
Co-Payments: We are required by our insurance contracts to collect all applicable co-pays at the time of service or by close of business the next
day. If a co-pay is not paid at the time of service, a $15 late fee will be assessed. This is in addition to a statement fee if applicable. (______)
High Deductible Insurance Plan: We require a copy of the health savings account debit/credit card, or personal credit card remains on file. There is
an addenda to this financial policy, which is signed separately. (______)
Payment Options if you are Uninsured or Out of Network: All visits and vaccines must be paid in full at the time of service. You must stop at
check-out to pay for your total charges. If payment cannot be made in full at the time of service, a payment agreement must be made prior to
the visit. (______)
Insurance Release: This is to certify that I have been informed that my health plan may not be liable for service rendered if any of the following
conditions apply:

Provider not participating in my health plan.

Unmet deductible under my health plan contract.

Services not covered under my health plan contract.

Well child check-ups, immunizations, hearing and vision screenings may not be covered by some insurance plans. Please check with your
insurance carrier if you are uncertain about coverage for routine services. If immunizations are not covered by your insurance, please
advised the nursing staff, prior to receiving vaccines, to receive lower cost state funded vaccines.
Returned Checks: There is a fee (currently $30) for any checks returned for insufficient funds. (______)
Ledgers: There is a fee (currently $10) if you need a print-out of your account, for payment history, etc. The fee is due prior to receiving the ledger.
(______)
After Hours Visits: Our Village Drive office offer extended hours for sick and emergent care. Please be advised that there is an additional fee of $25
for these visits. Any office visits scheduled on a day when our offices are typically closed on Saturdays, Sundays, or any holidays are considered
extended hours.
Walk-In Fees: All patients are seen by appointment only; however, there is a $35 fee for walk-ins where available.
Automobile Accidents: If your child is involved in an automobile accident, he/she must first be evaluated at a hospital ER. If your child requires
follow-up care with his/her primary care physician, we will provide this service, however, the visit is considered out of network as we do not have a
contract with auto insurance companies. These visits must be paid in full at the time of service.
Missed or Late Cancel Appointments: There is a $35 fee for all missed/no shows or if the appointment is not canceled with a 24 hour notice. If this
should happen more than twice, a $55 charge will be incurred for the third incident. All fees must be paid before a new appointment can be
scheduled. After three missed appointments, the practice may at its discretion choose to discontinue your care. (______)
Request or Transfer of Records: You will need to complete the authorization for disclosure to release medical records form, which can be obtained
from our office. This form must be completed in its entirety in order for us to process the request. A fee of $25 for the first 20 pages, and 50¢ for
each page thereafter, along with a reasonable fee for the actual costs of mailing, shipping or delivery will be assessed. There is a fee of $15 for
executing affidavits. **The $50 fee for 24 hour advance notice was removed since it does not justify “reasonable” cost based fees. Perhaps an
additional $15 fee can be added for administrative purposes since it is a rushed request.**
Divorced Parents: In case of divorce or separation, the parent or individual with whom the child resides, will be the parent responsible for all fees
for services rendered, independent of insurance coverage and/or what a divorce decree may state. It is the parent’s responsibility to collect from
the other parent. (______)
Newborns: Most insurance carriers require a newborn be added to the parent’s policy within 30 days. You are fully responsible for any fees
incurred if your newborn is not added within the allotted time. You may receive a statement within that time if we have not received verifiable
insurance information. Please contact the billing department once you have received your newborn’s active insurance information.
Secondary Insurance: Northeast Pediatric Associates, P.A. (A Division of Consultant in Women’s Health) does file secondary insurances to include
Medicaid provided that we are a participating provider for your secondary insurance, and the primary care provider listed for HMO or Medicaid. It
is your responsibility to check with your secondary insurance for the provider’s in-network participation.
Past Due Accounts: If your account becomes past due, we will take the necessary steps to collect this debt. If we refer your account to a
collection agency, you agree to pay all of the collection costs which are incurred. (______) If an account is referred to a collection agency, due to
non-payment, the providers of Northeast Pediatric Associates, P.A. (A Division of Consultant in Women’s Health) will no longer be able to provide
medical care to your children. In this case the guarantor will be notified of this by certified mail and given adequate time to find a new medical
provider. All accounts sent to the collection agency will be reported to the Credit Bureau.
Additional Fees: *(Payment for these additional services must accompany your request.)

Request for medical records – please see Medical Records Release Form

Health Forms (school, camp, sports, daycare, etc.) - $7

FMLA - $25

Medical necessity letters - $10 per letter

Administrative fee for rushed request - $5
Effective Date: I certify that my child/children is/are covered by the insurance provided and assign directly to Northeast Pediatric Associates, P.A.
(A Division of Consultant in Women’s Health), all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am
financially responsible for all charges whether or not paid by the insurance. I hereby authorize Northeast Pediatric Associates, P.A. (A Division of
Consultant in Women’s Health) to release all information necessary to secure the payment of benefits.
I have read the above financial policy for Northeast Pediatric Associates, P.A. (A Division of Consultant in Women’s Health) and I agree to the terms
and conditions contained herein.
Child’s Name
Print Name
Date of Birth
Signature of Parent/Legal Guardian
Date
A Division of Consultant In Women’s Health
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
By signing this form, I hereby acknowledge my receipt of Northeast Pediatric Associates, P.A.’s Notice of Privacy Practices which
explains how my child’s/children’s medical information will be used and disclosed. I understand that I am entitled to receive a copy
of this document.
Child/Children’s Name(s) and Date(s) of Birth:
_______________________________________
PARENT OR LEGAL GUARDIAN (PRINT)
_______________________________________
SIGNATURE OF PARENT OR AUTHORIZED REPRESENTATIVE
______________________
DATE
Acknowledgement NOT obtained because:
□ Patient, or legal representative, declined to accept Notice of Privacy Practices.
□ Patient received Notice of Privacy Practices, but refused to sign Acknowledgement form.
□ Other (briefly describe)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
______________________________________
EMPLOYEE NAME (PRINTED)
__________________________
DATE
________________________________________
EMPLOYEE SIGNATURE
NORTHEAST PEDIATRIC ASSOCIATES, P.A.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This practice uses and discloses health information about your child for treatment, to obtain payment for treatment, for
administrative purposes, and to evaluate the quality of care that your child receives.
This notice describes our privacy practices. We may change our policies and this notice at any time and have those
revised policies apply to all the protected health information we maintain. If or when we change our notice, we will post
the new notice in the office where it can be seen. You may request a paper copy of this notice, at any time (even if you
have allowed us to communicate with you electronically). For more information about this notice or our privacy
practices and policies, please contact the person listed at the end of this document.
1. TREATMENT, PAYMENT, HEALTH CARE OPERATIONS
a. Treatment: We are permitted to use and disclose your child’s medical information to those involved
in your child’s treatment. For example, your child’s care may require the involvement of a specialist.
When we refer your child to that physician, we will share some or all of your child’s medical
information with that physician to facilitate the delivery of care.
b. Payment: We are permitted to use and disclose your child’s medical information to bill and collect
payment for the services we provide to your child. For example, we may complete a claim form to
obtain payment from your insurer or HMO. That form will contain medical information, such as
description of the medical services provided to your child, that insurer or HMO needs to approve
payment to us.
c. Health Care Operations: We are permitted to use and disclose your child’s medical information for
the purposes of health care operations, which are activities that support the practice and ensure
that quality care is delivered. For example, we may engage a professional to assist us in reviewing
quality care issues.
2. DISCLOSURES THAT CAN BE MADE WITHOUT YOUR AUTHORIZATION
There are situations in which we are permitted to disclose or use your child’s medical information without your
written authorization or an opportunity to object. In other situations, we will ask for your written authorization
before using or disclosing any identifiable health information about your child. If you choose to sign an
authorization to disclose information, you can later revoke that authorization, in writing, to stop future uses and
disclosures. However, any revocation will not apply to disclosures of uses already made or that rely on that
authorization.
a. Public Health, Abuse, or Neglect, and Health Oversight: We may disclose your child’s medical
information for the public health activities. Public health activities are mandated by federal, state,
or local government for the collection of information about disease, vital statistics (like births and
death), or injury by a public health authority. We may disclose medical information, if authorized by
law, to a person who may have been exposed to a disease or may be at risk for contracting or
spreading a disease or condition. We may disclose your child’s medical information or report
reactions to medications, problems with products, or to notify patients of recalls of products they
may be using.
i.
Because Texas law requires physicians to report child abuse or neglect, we may disclose
medical information to a public agency authorized to receive reports of child abuse or
neglect. Texas law also requires a person having cause to believe that an elderly or disabled
person is in a state of abuse, neglect, or exploitation to report the information to the state,
and HIPAA privacy regulations permit the disclosure of information to report abuse or
neglect of elders or the disabled.
ii.
We may disclose your child’s medical information to a health oversight agency for those
activities authorized by law. Examples of these activities are audits, investigations, licensure
applications and inspections, which are all government activities undertaken to monitor the
health care delivery system and compliance with other laws, such as civil rights.
b. Legal Proceedings and Law Enforcement: We may disclose your child’s medical information in the
course of judicial or administrative proceedings in response to an order of the court (or
administrative decision-maker) or other appropriate legal process. Certain requirements must be
met before the information is disclosed.
i.
If asked by law enforcement officials, we may disclose your child’s medical information
under limited circumstances. We also may release information if we believe the disclosure
is necessary to prevent or lessen an imminent threat to the health or safety of a person.
c. Worker’s Compensation: We may disclose your child’s information as required by workers’
compensation law.
i.
Inmates: if you are an inmate, or under the custody of law enforcement, we may release
your medical information to that correctional institution or law enforcement official. This
release is permitted to allow the institution to provide you with medical care, to protect
your health and safety of others, or for the safety and security of the institution.
ii.
Military, National Security and Intelligence Activities, Protection of the President: We may
disclose your medical information for specialized governmental functions such as separation
or discharge from military service, requests as necessary by appropriate military command
officers (if you are in the military), authorized national security and intelligence activities, as
well as authorized activities for the provision of protective services for the president of the
United States, other authorized government officials, or foreign heads of state.
iii.
Research, Organ Donation, Coroners, Medical Examiners, and Funeral Directors: When a
research project and its privacy protections have been approved by an institutional review
board or privacy board, we may release medical information to researchers for research
purposes. We may release medical information to organ procurement organizations of the
purpose of facilitation organ, eye, or tissue donation if you are a donor. Also, we may
release your medical information to a coroner or medical examiner to identify a deceased
person or cause of death. Further, we may release your medical information to a funeral
director when such a disclosure is necessary for the director to carry out his duties.
iv.
Required by Law: We may release your medical information when the disclosure is required
by law.
3. YOUR RIGHTS UNDER FEDERAL LAW
The U.S. Department of Health and Human Services created regulations intended to protect patient privacy as
required by the Health Insurance Portability and Accountability Act (HIPAA). Those regulations create several
privileges that patients may exercise. We will not retaliate against patients who exercise their HIPAA rights.
a. Requested Restrictions: You may request that we restrict or limit how your child’s protected health
information is used or disclosed for treatment, payment, or health care operations. We do NOT
have to agree to this restriction, but if we do agree, we will comply with your request except under
emergency circumstances.
b. Receiving Confidential Communications by Alternative Means: You may request that we send
communications of protected health information by alternative means or to an alternative location.
This request must be made in writing to the person listed below. We are required to accommodate
only reasonable requests. Please specify in your correspondence exactly how you want us to
communicate with you and, if you are directing us to send it to a particular place, provide the
contact/address information.
c. Inspection and Copies of Protected Health Information: You may inspect and/or copy health
information that is within the designated record set. Any such request must be made in writing to
the person listed at the end of this document. We will respond within 60 days of your request. We
may refuse to allow an amendment.
d. Amendment of Medical Information: You may request an amendment of your child’s medical
information in the designated record set. Any such request must be made in writing to the person
listed at the end of this document. We will respond within 60 days of your request. We may refuse
to allow an amendment.
e. Accounting of Certain Disclosures: HIPAA privacy regulations permit you to request, and us to
provide, an accounting of disclosures that are other than for treatment, payment, health care
operations, or made via an authorization signed by you or your representative. Please submit any
request for an accounting to the person at the end of the document. Your first accounting of
disclosures (within a 12 month period) will be free. For additional requests within that period we
are permitted to charge for the cost of providing the list. If there is a charge we will notify you, and
you may choose to withdraw or modify your request before any costs are incurred.
4. APPOINTMENT REMINDERS, TREATMENT ALTERNATIVES, AND OTHER BENEFITS
We may contact you by (telephone, mail, or both) to provide appointment reminders, information about
treatment alternatives, or other health-related benefits and services that may be of interest to you.
5. COMPLAINTS
If you are concerned that your child’s privacy rights have been violated, you may contact the person listed
below. You may also send a written complaint with us or the government.
6. OUR PROMISE TO YOU
We are required by law and regulation to protect the privacy of your child’s medical information, to provide you
with this notice of our privacy practices with respect to protected health information, and to abide by the terms
of the notice of privacy practices in effect.
7. QUESTIONS AND CONTACT PERSON FOR REQUESTS
If you have any questions or want to make a request pursuant to the rights described above, please contact:
PAUL ROBINSON – PRACTICE ADMINISTRATOR
NORTHEAST PEDIATRIC ASSOCIATES, P.A., 8606 VILLAGE DRIVE, SUITE A, SAN ANTONIO, TEXAS 78217
PHONE: (210) 657-0220
A Division of Consultant In Women’s Health
PREVENTIVE CARE SCHEDULE
st
Hospital 1
2-5 Day
2 Wk or 1 mo
2 Months
4 Months
6 Months
9 Months
12 Months
15 Months
18 Months
24 Months
30 Months
3 Years
4 Years
5-6 Years
7 Years
8 Years
9 Years
10 Years
11 Years
12 Years
13-14 Years
15 Years
16 Years
17 Years
18+ Years
Hepatitis B given
Hospital F/U
WCC, Hepatitis B #1 (if not given in hospital)
WCC, Pediarix #1 (DTaP #1, Hep B #2, IPV #1), Hib #1, Prevnar #1, Rotateq/Rotarix #1
WCC, Pediarix #2 (DTaP #2, Hep B #3, IPV #2), Hib #2, Prevnar #2, Rotateq/Rotarix #2
WCC, Pediarix #3 (DTaP #3, Hep B #4, IPV #3), Hib #3, Prevnar #3, Rotateq #3, Influenza Vaccine
WCC, Influenza Vaccine (if have not received 2 doses this season), PEDS questionnaire
WCC, MMR #1, Varicella #1, Prevnar #4, Influenza Vaccine (if have not received 2 doses this season), Hct, Lead
WCC, DTaP #4, Hib #4, Hepatitis A #1, Influenza Vaccine (if have not received 2 doses this season)
WCC, Influenza Vaccine, MCHAT, PEDS questionnaire
WCC, Hepatitis A #2, Varicella #2, Prevnar 13 (if indicated), Influenza Vaccine, Pneumovax (high risk patients), Hct,
Lead, Cholesterol (if high risk), MCHAT, PEDS questionnaire
WCC (after cleared with pt’s insurance), Influenza Vaccine, Prevnar 13 (if indicated)
WCC, Varicella #2 (if not yet received), Influenza Vaccine, Prevnar 13 (if indicated), Vision screen (recommended),
PEDS questionnaire
WCC, DTaP #5, IPV #4, MMR #2, Varicella #2 (if not yet received), Prevnar 13 (if indicated), Influenza Vaccine,
Hearing and Vision screen, PEDS questionnaire
WCC, Varicella #2 (if not yet received), Influenza Vaccine, Hearing and Vision screen (recommended)
WCC, Varicella #2 (if not yet received), Influenza Vaccine
WCC, Varicella #2 (if not yet received), Influenza Vaccine, Hearing and Vision Screen (recommended)
WCC, Varicella #2 (if not yet received), Influenza Vaccine, Cholesterol screening once age 9-11
WCC, Varicella #2 (if not yet received), Influenza Vaccine, Cholesterol screening once age 9-11, Hearing and Vision
screen (recommended)
WCC, TDaP, MCV #1, Varicella #2 (if not yet received), HPV #1, Influenza Vaccine, Cholesterol screening (if not done
at age 9 or 10), PSC-Y questionnaire for patient, PSC questionnaire for parent
WCC, Finish HPV series if not already done, Influenza Vaccine, Females Hct once age 12-16, Vision screen
(recommended), PSC-Y questionnaire for patient, PSC questionnaire for parent
WCC, Influenza Vaccine, Females Hct once age 12-16, PSC-Y questionnaire for patient, PSC questionnaire for parent
WCC, Influenza Vaccine, Females Hct once age 12-16, Hearing and vision screen (recommended), PSC-Y
questionnaire for patient, PSC questionnaire for parent
st
WCC, MCV #2 (if 1 dose given at 15 yrs or younger), Influenza Vaccine, Females Hct once age 12-16, PSC-Y
questionnaire for patient, PSC questionnaire for parent
WCC, MCV #2 (if not given previously), Influenza Vaccine, Cholesterol screening once age 17-21, PSC-Y
questionnaire for patient, PSC questionnaire for parent
WCC, MCV #2 (if not given previously), Influenza Vaccine, Cholesterol screening once age 17-21, Vision screen
(recommended at 18 yrs), PSC-Y questionnaire for patient, PSC questionnaire for parent
NOTES: WCC = Well Child Check; Hct = Hematocrit (screening for anemia); MCHAT, PEDS, PSC and PSC-Y questionnaires screen for
developmental and behavioral problems. Missed vaccines may be recommended at any visit. Influenza vaccines are given August
thru March and are recommended for ALL patients 6 mos and up. Cholesterol screening may be recommended at any age 2 and up
based on your family’s history.
Tuberculosis screening questions are asked at all annual visits age 1-20.