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New Patient Registration

  • 1First step
  • 2Patient Demographics

  • 3Emergency Demographics
  • 4Parent's Demographics
  • 5Insurance Detail
  • 6Patient History Sheet - Social
  • 7Past History
  • 8Developmental

    For infants to 24 months child, please review the Developmental Milestones of the child and list the age the milestones was achieved

    #Developmental MilestonesExpected DatesList Below Date Developmental Milestone achieved or Age
    1Head up 45 degrees; Lifts head2 months
    2Smile spontaneously;Smile responsively2 months
    3Roll over; Sit with head steady4 months
    4Grasp rattle; Turn to see rattling sound; Laugh4 months
    5Sit- No Support; Roll over6 months
    6Feed self; Work to obtain toy that is out of reach6 months
    7Pull to stand; Stand holding up9 months
    8Says DADA/MAMA- Nonspecific; Use single syllables9 months
    9Wave Bye-Bye; Imitates activities9 months
    10Walks well; Walk Backwards; Stops and Recovers15 months
    11Speak 1 word; Speak 3 words15 months
    12Removes clothing; Run; Walks up stairs18 months
    13Dresses themselves; Combines Words24 months
  • 9Family History
    Traveled outside USA
    Mood Disord
    High Blood Pressure
    Exposure to HIV
    Heart Disease
    Exposure to TB
    Coronary Artery Disease
    Drug Abuse
    Maternal Depression
    High Cholesterol
    Behavioral Disorder
  • 10Family Health Habits
    How strong are your family’s religious beliefs or practices?
    How often does your family eat meals together?
    How often does your child use a seatbelt? (Car seat)?
    Does your child ride a bicycle?
    If yes, how often he/she use a helmet?
    What kind of guns are in your home?
    If you have a gun at home, is it locked up?
    Does your child use a toothpaste with fluoride in it?
    Do you help your child with tooth brushing?
    How often do you brush your teeth?
  • 11Assignment of Benefits Form

    I herby instruct and direct

    Insurance Company to pay by check made out and mailed to : Najmus Sehr Ansari P.L.C, 7037 Rose Ave, Orlando, FL 32810


    If my current policy prohibits direct payment to a doctor, I herby also instruct and direct you to make out the check to me and mail it as follows: 7037 Rose Ave, Orlando FL 32810.

    For the professional or medical expenses benefits allowable and otherwise payable to me under my current insurance policy as payment towards the total charges for the professional services rendered. THIS IS DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay, in current manner, any balance of said professional service charges over and above this insurance payment.

    A photocopy of this assignment shall be considered as effective and valid as the original. I authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.

    I authorize doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf.

  • 12Financial Policy

    Thank you for choosing us as your child’s health care provider. We are committed to providing your child comprehensive Pediatric care. Please understand that payment of your child’s bill is considered part of their treatment. The following is a statement of our financial policy which we require you to read and sign prior to any treatment. ALL PARENTS MUST COMPLETE ALL PAPERWORK BEFORE THEIR CHILD IS SEEN.

    PAYMENT IS DUE AT THE TIME OF SERVICE. WE ACCEPT CASH Only. If a check is returned to us for any reason, your child’s account will be charged the amount of the check plus a $ 25.00 returned check fee. Parents will be responsible for any fees incurred from collection agencies and/or legal services hired by POWERS PEDIATRICS to secure payment for services.


    Our practice is committed to providing the best treatment for our patients and 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 or customary rates.


    WE CANNOT BILL YOUR INSURANCE COMPANY UNLESS YOU GIVE US A COPY OF YOUR CHILD’S INSURANCE CARD. Without a copy of the card, you will be responsible for 100% of the charges on that date of service. We will file to your insurance company; however, if you must pay a percentage of the bill, it must be paid at the time of service. All co-pays are due at the time of service.

    The balance is your responsibility whether your insurance company pays or not. Your insurance policy is a contract between you and your insurance company. Please be aware that some, and perhaps all of the services provided may be non-covered services and not considered reasonable according to your insurance policy.

    According to Florida State statutes, an HMO has 45 days to process and pay a correct claim. If your insurance has not paid your child’s claim in full within 6 months, you will be responsible for the bill within 10 days of receipt of your statement.

    We will mail 2 statements to you before the account is turned over to a collection agency. If you are unable to pay the balance in full, we can arrange a payment plan for you which you will sign. A copy of the payment plan will be given to you and copy will be kept in your child’s chart. If you default on your payment plan, the account will be forwarded to a collection agency.

    In the event that your insurance changes, it is your responsibility to notify us as we may be non participating providers. Failure to do so will result in you being responsible for all charges incurred. It is not the responsibility of POWERS PEDIATRICS to ensure we are providers. Our main concern is the health of our patients.

    Regarding HMO, Managed Care and Medicaid plan, you are responsible for making sure that our practice and/or doctors are listed as your child’s Primary Care Physicians. Failure to do so will result in you being responsible for all charges incurred.


    I hereby assign all medical and/or surgical benefits to include major medical benefits to which my child is entitled to POWERS PEDIATRICS. A photocopy of my child’s insurance card is to be considered as valid as the original the original. I hereby authorize POWERS PEDIATRICS to release all information necessary including medical records, if any, to any third party payer to secure payment. My signature constitutes a lifetime authorization

    Your Signature Below Confirm that you fully understand POWERS PEDIATRICS financial policy.

    Do you have trouble affording the care or prescriptions prescribed?
  • 13HIPAA Patient Questionnaire
    1. Please list the family members or other person(s), if any, whom we may inform about your general medical condition and your diagnosis (including treatment, payment and health care operations):
    2. Please list the family members or others, if any, whom we may inform about your medical condition ONLY IN AN EMERGENCY.
    3. Please print the address of where you would like your billing statements and/or correspondence from our office to be sent if other than your home. (Confidential Communications)
    4. Please indicate if you want all correspondence from our office sent in a sealed envelope marked “CONFIDENTIAL”.
    5. Please print the telephone number or email address where you want to receive calls about your appointments, labs and x-rays results or other health care information:
    6. Can confidential messages (ie., appointment reminders) be left on your telephone answering machine or voicemail?

    I understand the Privacy Protection Act and have been offered a copy of the Organization’s Notice of Privacy Practices updated for the HITECH Omnibus Rule of 2013.

  • 14Consent for Treatment

    I consent to the use of disclosure of my protected health information by Powers Pediatrics for the purpose of diagnosing or providing treatment to me/my child, obtaining payment for me/my child’s health care bills or to conduct health care operations of Powers Pediatrics.

    I have the right to revoke this consent, in writing, at any time, except to the extent that Powers Pediatrics has taken action in reliance on this consent.

    Me/my child’s “protected health information” mean health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to me/my child, or there is a reasonable basis to believe the information may identify me/my child.

    POWERS PEDIATRICS has an established privacy policy which is displayed in this office and I can request a printed copy of this policy.


    I give authorization to the provider listed below to disclose a copy of the specific health/medical information identified below:

    TO: (Name, Address, Phone of Recipient of Records)

    RECORDS FROM: (Who is Releasing the Records)

    For the Following Purposes (Circle one)
    By Circling Below, I Specifically Authorize the Use and/or Disclosure of the Following Health Information And/or Medical Records, If Such Information And/or Records Exist:
    The Following Items Must Be Initialed to Be Included in the Use And/or Disclosure:

    I understand that, if the person or entity receiving the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by HIPAA and other federal and state regulations. However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements.

    I also understand that the person I am authorizing to use and/or disclose the information may not receive compensation for doing so.

    I, further understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment of my eligibility for benefits. I may inspect or copy any information to be used and/or disclosed under this authorization.

    Finally, I understand that I may revoke this authorization, in writing, at any time, provided that I do so in writing, except to the extent that action has been taken in reliance upon this authorization. Unless Revoked Earlier, this Authorization Will Expire in Six (6) Months from the Date of