Document 6443935

Juan Jose Fer:'eris, M.D FAAP
Helen PerEz, 1VL D F.AA_P
Omst::Jpher Guide, M.D. F.AAP
Patient Legal Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ .
Christina lvfer;-itt, M.D. FA.PcP
DOB:
-------­
Mailing Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _City _ _ _ _ _ _ _ _ _TX 78_ __
Primary Phone:
Pharmacy Name
Primary Care Physician: ______________
& Address:
Pharmacy Phone:
Parents/Guardians Information
~ather's
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ SSt\!# _ _ _ _ _ _ _ DOB: ________
Father's Cell #:
__________ Home #: _ _ _ _ _ _ _ _Other #:
Mother's Name: ------.--------- SSN# --- --Mother's Cell #:
Home #:
---_ .. _-­
---­ DOB:
Other #:
Guarantor Information Guarantor Name: _____________TX DL#_ _ _ _ _ _ _ SSN#_ _-_ _-_ _ M/F: _ DOB:
---------
Relationship to patient: _ _ _ _ _ Phone: _ _ _ _ _ _ _ _ __ .Billing Address: ____________________
_ __________ TX78_ __ 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 Jnderstand and agree that (regardless of my insurance status) I am ultimately respons:bie for the balance of my account for any
professional services rendered. I have read all of the infOimation 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 ir.sura nee policy benehs to the doctor for payment of the tota charges
for professional services rendered. I 3,$0 aJthorize the release of any information pertinent to my case to any insurance company,
adjuster, attorney or other health care professional hvolved in my account/treatment. All patients must first stop at the reception desk
to satisfy any co-payments prior to seeing t1e physician.
Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Today's Date: _ _ _ _ _ _ _ __
CHILDREN FIRST PEDIATRICS
AcknowledgenlentForm
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. 1 understand that this information serves as:
o
A basis Jor planning my care and treatment
• A means ojcommunication among the many health proJessionals who contribute to my care
• A source ojinJormation Jor applying my diagnosis and surgical inJormation to my bill
• A means by which a third-party payer can verify that services billed were actually provided
.. And a toolJor routine healthcare operations such as assessing quality and reviewing the competence oj
healthcare 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 infonnation maintained by Children First
Pediatrics.
I understand that I have the 1'ight 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 infonnation 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 Cbildren 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 acknowledgementlconsent because:
o
o
Emergency\
Patient Sedated
o
Patient Non-Responsive
o Patient Confused/Disoriented
Reason _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
o Patient Refused -
(Same date as the Notice of Privacy Practices)
Effective Date of the Notice of Privacy Practices
CHILDREN FIRST PEDIA TRICS
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) t~~;\
ptftn'f4" dlitiTiU4J 8627 Cinnamon Creek Bldg.l
San Antonio, Texas 78240
641-KIDS
Payment/Eligibility Form
1, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , hereby certify that I am eligible for
(name of insured)
_ _ _~~_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ as of _ _ _-,.:: _,---:--_____ , through
(insurance)
(effective date)
_______________ and I have chosen Dr. _ _~.~_ _ _ _ _ _ _ _ _ _ _ _~ _ _ _ __
(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 Parent/Guardian _______________________ Date _ _ _ _ _ _ _ _ __
Signature of Receptionist
___________________ Date _ _ _ _ _ _ _ _ __
Children First Pediatrics
Insurance Coverage Waiver
I understand that my eligibility for coverage by my insurance company_ _ _~_ _ _ _~_
cannot be confirmed at this time. I wish to receive medical service from Children First Pediatrics.
If it is determined that my child/children are not eligible for coverage, I understand that I will be
responsible for payment of all services provided. I also understand that if my insurance has terminated and I have not provided Children First Pediatrics with new insurance coverage I will be responsible for payment for al/ services provided. Patient Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~_ __
Signature of Parent/Legal Guardian: _ _ _ _ _ _ _ _ _ _ _ _ __
8627 Cinnamon Creek Bldg. 1 San Antonio, Texas 78240 641-KIDS
Pediatric History
Child's
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Sex: 0 M
0 F
DOB: _________________________
BIR1B HISTORY Pregnancy Problems _____________________________________________ o Alcohol
o Recreation Drug
Matemal Use:
0 Cigarettes
0 Medications
Birth Wt: ________._ _ _ Length: _________ Gestation: __________________
Delivery: ____________________________________________
Nursery Stay: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~---------~---Neonatal Screen: ___________________________________.~_ __ Developmental Problems: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~_ _ _ _ _ _ _ _ _ __ Safety Issues:
0 Car Seat
o Guns in Home
FAMILY HISTORY
o ADD / ADHD /Leaming Problems
o AIDS
o Allergy Problems
o Anemia/Blood Problems
o Smoke Alarms
o Day Care
o Secondary Smoke o Flouride Supplement
FAMILY PROFILE
o Father t-JMV\B;
o Mother lID:..YVt.J..::e",,--'·_ _ _ _ _ _ _ _ _ _ _ _ _.____
o Siblings !..::CNft~m:=:r,~'·_ _ _ _ _ _ _ _ _ _ _ _ __
o Asthma
o Birth Defects
o Cancer
o Cardiac Murmurs
o Diabetes Mellitus
o Hearing Problems
o Heart attacks/Stroke <50 yrs
o High Blood Pressure
o High Cholesterol
o Lung Disease/TB
o Mental Illness
o Renal Problems
o Seizures
o Substance Abuse
o Step Family _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
NOTICE OF HEALTH INFORMATION PRACTICES
ACKNOWLEDGEMENT FORM
(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 o/the 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 Information
C]1iklr8n First PediatriCS
. I understand that the organization reserves
Practices of
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 information 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 T1zis notice describes how medical in/ormation about you may be used and disclosed alld how you call get
access to this ill/ormation. Please see the receptionist to request a copy.
•
Understanding Your Health Record/Information Each time you Visit a hospital, physician or other
healthcare provider. a record of your visit is made
Typically. this record containS your symptoms,
examination and test results, diagnoses, treatment
and a plan for future care or treatment. This
infonllation. often referred to as your health or
medical record, serves as a:
•
•
•
•
•
•
•
•
•
basis for planning your care and treatment
means of communicatioll among [he many
health professionals who contribute to your
care
legal document describing the care you
received
mealls by whiell you or a third-party payer
can verify that services billed were actually
provided
tool in educatmg health professionals
source of data for medical research
source of information for public health
officials charged with improving the health of
the nation
source of data for facility planning and
marketing
tool with which we can assess and
continually work to improve the care we
render and the outcomes we achieve
Understanding what is in your record and how your
health information is used helps you to
• ensure its accuracy
• better understand who, what, when. where
and why others may access your health
infornlation
• make more lIlfomled decisions when
authorizing disclosure to others
Your Health Information Rights
Although your health record is the physical
property of the healthcare practitioner or facility
that compiled it, the information belongs to you.
You have the right to;
•
request a restriction on certain uses and
disclosures of your information as provid~d
by 45 CFR 164.522
• obtain a paper copy of the notice of
infomlation practices upon request
• inspect and obtain a copy of your health
record as provided for in 45 CFR 164.524
• amend your health record as provided in 45
CFR 164,528
• obtain an accounting of disclosures of your
health information as provided in 45 CFR
J 64.528
• request communications of your health
infonllation by alternative means or at
alternative locations
• revoke your authorization to use or disclose
health infonllatioll except to the extent that
action has already been taken
•
•
•
•
We reserve tile right to change our practices and to
make the new provisions effective for all protected
health information we maintain,
Should our
infonnation practices change, we will mail a
revised notice to the address you have supplied us.
We will not use or disclose your health infonnatioll
without your written authorization, except as
described in this notice.
To Report a Problem
If you have questions and would like additional
information, you may contact the Privacy Offi cer
at this office,
If you believe your privacy rigllts have been
violated. you can file a complaint With this office
or with the secretary of Health and Human
Services, There will be no retaliation for filing a
complaint
Examples of Disclosures for Treatment,
Payment and Health Operations
Treatmel1f:
Information obtained by a nurse.
physician or other member of your health care team
will be recorded 111 your record and used to
determine the course of treatment that should work
best for you Your physician will document in
your record his or her expectations of the members
of your healthcare team.
Members of your
healthcare team will then record the actions they
took and their observations. In that way. the
physician will know how you are responding to
treatment.
We will also provide subsequent
health care providers with copies of various reports
that should assist tllem in treating you,
A bill may be sent to you or a third­
party payer This infonnation on or accompanying
the bill may include information that identifies you.
as well as your diagnosis. procedures and supplies
used,
PaYl1lellf:
Healtlf Opemtiolls:
I
2
Our Responsibilities Tilis organization is required to' I •
,
I
maintain the
infonnation
privacy
of
your
health
provide you with a notice as to our legal
duties and privacy practices WIth respect to
information we collect and maintain about
you
abide by the tenns of this notice
notify you if we are unable to agree to a
requested restriction
accommodate reasonable requests you Illay
have to commullicate health infonnation by
alternative means or at alternative locations
notify you of a breach of "unsecured"
protected health infomJation
Risk !\Yanagemcnt - Members ofthe medical staff or the risk or quality improvement staff may use infonnation in your health record to assess the care and outcomes in your case and others like it. This information will then be
used in an effort to continually improve the
quality and effectiveness of the healthcare
and service we provide,
Business Associates _ There are some
services provided in our organization through
contacts with business associates. Examples
incl ude radiology. laboratory, copy services.
transcription sen'ices, billing services. etc.
When these services are contracted. we inay
disclose your health infonnation to our
the job we have asked them to do and bill you
or your third-party payer for services
rendered, To protect your health information,
however, we require the business assoCiate to
appropriately safeguard your infonnation
3. Notification - We may use or disclose
information to notify or assist in nollfying a
family member, personal representative, or
another person responsible for your care, of
your location and general condition.
4. Communication With Family
Health
professionals. using their best jUdgment, may
disclose to a family member, other relative.
close personal friend or any other person you
identify, health information relevant to that
person's involvement in your care or pa}1llent
related to your care,
5. Research - We may disclose infomlation to
researchers when their research has been
approved by an institutional review board that
has reviewed the research proposal and
established protocols to ensure the privacy of
your health information.
6. Funeral Directors - We may disclose ilealiJl
infonnatioll to funeral directors consistent
with applicable law to carry out their duties,
7. Organ Procurement Organizations ­
Consistent with applicable law. we may
disclose health infonnation to organ
procurement organizations or other entities
engaged in Ule procurement, bankmg or
transplantation of organs for the purpose of
tissue donation and transplant
8. Marketing - We may contact you to proVide appointment reminders or information about treatment alternatives or other ilealtll-related benefits and services that may be of interest to you, 9. Food and Drug Administration (FDA) ­
We may disclose to the FDA health mfonnation relative to adverse events with respect to food, supplements, product and product
defects.
recalls.
repairs
or replacement 10. Workers' Compensation We llJay disclose health infonllation to the extent authorized by and to the extent necessary to comply with laws relating to workers' compensation or other similar programs established by law. J I. Public Health - As required by law. we may disclose your health infornlatlon to public health or legal auUlOrities charged with preventing or controlling disease, injury or disability. 12 Law Enforcement We llJay disclose health information for law enforcement purposes as required by law or in respollse ro a valid subpoena, Federal law makes proviSion for YOllr health
information to be released to an appropriate health
oversight agency. public health authority or
attorney, provided that a work force member or
business associate believes in good faith that we
have engaged in unlawful conduct or have
otherwise vio:ated profeSSional or clinical
standards and are potentially endangering one or
more patients, workers or the public
TlIis notice is effecth'e as oJ11112010 IIlId
will rell/ain ill effect umil revised.
I
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