New Patient Registration

1First step
Your Name*
Relationship With Patient*
Upload ID
Choose file
How did you hear about us?*
2Patient Demographics
Patient Name*
Patient DOB*
Home Address*
Patient SSN
City*
State*
Zip*
Cell Phone
Home Phone*
Email*
Race
Ethnicity
Language
Communication Barriers(If Any)
Vision
Hearing
3Emergency Demographics
Emergency Contact
Relationship
Phone
4Parent's Demographics
Parent’s Marital Status*
Single
Married
Divorced
Widowed
Mom's Name
Mom’s DOB
Mom’s Phone
Mom’s SSN
Mom’s Employer
Work Phone
Mother’s Education
Dad’s Name
Dad’s DOB
Dad’s Phone
Dad’s SSN
Dad’s Employer
Work Phone
Dad’s Education
Do your Signature
Clear
5Insurance Detail
Front ID
Choose file
Back ID
Choose file
Insurance Company
Under Who
Member ID Or Policy
Group # (If applicable)
Claim Address
6Patient History Sheet - Social
Lives With
Brothers
Sisters
Pets
Siblings names and DOBs
Smoker in Household
Who(Smoker Name)
Alcohol use in Household
Who
Domestic abuse/violence(If Any)
Verbal
Physical
Sexual
Explain Situation(Domestic abuse/violence)
7Past History
Any Complication during Pregnancy
Explain(Complication during Pregnancy)
Labor
Delivery
Birth Weight
Hospital Name Child Was Born In
At Birth: Hep B
Hearing Screen
Any Hospital Admission
Explain(Hospital Admission)
Any illness
Explain(Illness)
Any medication
Any known allergies

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

#	Developmental Milestones	Expected Dates	List Below Date Developmental Milestone achieved or Age
1	Head up 45 degrees; Lifts head	2 months	Yes No Delayed
2	Smile spontaneously;Smile responsively	2 months	Yes No Delayed
3	Roll over; Sit with head steady	4 months	Yes No Delayed
4	Grasp rattle; Turn to see rattling sound; Laugh	4 months	Yes No Delayed
5	Sit- No Support; Roll over	6 months	Yes No Delayed
6	Feed self; Work to obtain toy that is out of reach	6 months	Yes No Delayed
7	Pull to stand; Stand holding up	9 months	Yes No Delayed
8	Says DADA/MAMA- Nonspecific; Use single syllables	9 months	Yes No Delayed
9	Wave Bye-Bye; Imitates activities	9 months	Yes No Delayed
10	Walks well; Walk Backwards; Stops and Recovers	15 months	Yes No Delayed
11	Speak 1 word; Speak 3 words	15 months	Yes No Delayed
12	Removes clothing; Run; Walks up stairs	18 months	Yes No Delayed
13	Dresses themselves; Combines Words	24 months	Yes No Delayed

9Family History
Mother Healthy*
If No Explain(Mother Health)
Father Healthy*
If No Explain(Father Health)
Siblings Healthy*
If No Explain(Siblings Health)
Paternal Grandparents Healthy
If No Explain(Paternal Grandparents Health)
Maternal Grandparents Healthy
If No Explain(Maternal Grandparents Healthy)
Traveled outside USA
Yes
No
Diabetes
Yes
No
Mood Disord
Yes
No
High Blood Pressure
Yes
No
Exposure to HIV
Yes
No
Anger
Yes
No
Heart Disease
Yes
No
Exposure to TB
Yes
No
Schizophrenia
Yes
No
Coronary Artery Disease
Yes
No
Bipolar
Yes
No
Drug Abuse
Yes
No
Cancer
Yes
No
ADHD
Yes
No
Maternal Depression
Yes
No
High Cholesterol
Yes
No
Behavioral Disorder
Yes
No
Please explain any family Member’s behavior health problem
Please list the child’s health concerns in order of importance. When did it begin?
Reason for your visit today
10Family Health Habits
How strong are your family’s religious beliefs or practices?
Very Strong
Moderately Strong
Not Strong
N/A
How often does your family eat meals together?
Frequently
Often
Occasionally
Rarely
Never
How often does your child use a seatbelt? (Car seat)?
Never
Rarely
Sometimes
Often
Always
Does your child ride a bicycle?
Never
Rarely
Sometimes
Often
Always
If yes, how often he/she use a helmet?
Never
Rarely
Sometimes
Often
Always
What kind of guns are in your home?
Handgun
Shotgun
Rifle
Other
None
If you have a gun at home, is it locked up?
Yes
No
N/A
Does your child use a toothpaste with fluoride in it?
Yes
No
Do you help your child with tooth brushing?
Yes
No
How often do you brush your teeth?
More than once day
Once a day
Less than once a day
What does your family do together for fun?
Any Concerns of oral of oral/dental health
11Assignment of Benefits Form
Date
Patient Name
Parent / Guardian
Claim Group
SSN # / ID
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
Or
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.
Date
Relationship to Patient
Witness
Do your Signature
Clear
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.
USUAL & CUSTOMARY RATES
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.
INSURANCE
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.
BENEFIT ASSIGNMENT/RELEASE OF INFORMATION
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?
Yes
No
Parent’s name
Patient’s name
Date
Do your Signature
Clear
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):
Name
Phone Number
Name
Phone Number
Name
Phone Number
2. Please list the family members or others, if any, whom we may inform about your medical condition ONLY IN AN EMERGENCY.
Name
Phone Number
Name
Phone Number
Name
Phone Number
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)
Address
City
State
Zip
4. Please indicate if you want all correspondence from our office sent in a sealed envelope marked “CONFIDENTIAL”.
Yes
No
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:
Home phone number
Email Address
6. Can confidential messages (ie., appointment reminders) be left on your telephone answering machine or voicemail?
Yes
No
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.
Patient Name
Date
Do your Signature
Clear
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.
Patient Name
Date
Relationship to patient
Do your Signature
Clear
15AUTHORIZATION TO USE AND/OR DISCLOSE MEDICAL RECORDS
I give authorization to the provider listed below to disclose a copy of the specific health/medical information identified below:
Name of patient
Date of birth
SSN
TO: (Name, Address, Phone of Recipient of Records)
Name
Address
Phone
City/State Zip
RECORDS FROM: (Who is Releasing the Records)
Name
Address
Phone
City/State Zip
For the Following Purposes (Circle one)
Continued Medical Care
Personal Information
Legal Follow-up
Disability Insurance
Other
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:
1. Office Notes and Reports
2. Diagnostic Reports
3. Billing Statements
4. Rx History
5. Transcribed Hospital Reports
6. Laboratory Reports
The Following Items Must Be Initialed to Be Included in the Use And/or Disclosure:
HIV/AIDS relate information and/or records HBV, TB or Other Communicable Diseases.
Genetic Testing Information and/or records
Mental Health Information and/or Records
Domestic Violence
Drug/Alcohol diagnosis, treatment or referral information (Federal regulations require a description of how much and what kind of information is to be disclosed.)
Describe
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
Signing or until (Insert Date):
Patient Name
Name of Legal Representative (if applicable)
Relationship to patient
Do your Signature
Clear

New Patient Registration

USUAL & CUSTOMARY RATES

INSURANCE

BENEFIT ASSIGNMENT/RELEASE OF INFORMATION

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

RECORDS FROM: (Who is Releasing the Records)