Welcome to 18 & Under MD

Transcripción

1 Welcome to 18 & Under MD Thank you for choosing 18 & Under MD. We appreciate the opportunity to provide your child with the highest quality pediatric care available. Whether you are seeking your baby s first pediatrician or looking for a doctor to help your teenager transition into adulthood, we provide a wide range of services including diabetes education and management as well as developmental pediatrics and lactation consultations. We offer emergency medical support 24 hours a day, 7 days a week by calling our regular office number (972) This includes regular business hours and Saturday sick clinic as well as after hours on call service. We utilize the Children s Health Nurse Advice line for our afterhours questions. This is a 24 hour service that is available any time our office is closed or we are not able to be reached. If you have medical coverage with a managed care plan, please be sure to notify your health plan of the doctor you have selected prior to your first visit to ensure coverage. If you are unable to provide proof of insurance, or if your child is not insured, we will still see your child although payment in full will be required at the time of service. The parent requesting care is the responsible party for all charges incurred at that visit. Our office does not accept any form of Medicaid as a primary insurance. In order to allow adequate time for sick visits, we ask that you provide our office a 24 hour notice prior to cancelling or rescheduling a visit if possible. There will be a $25 charge after two missed appointments without the minimum required notice.

2 18 and Under MD 3041 Churchill Dr. Suite 300, Flower Mound, TX Phone: (972) Fax: (972) PATIENT REGISTRATION FORM PATIENT NAME: Patient s Preferred Name: of Birth: SS #: Gender: M F Age: Address: Home Phone: City: State: Zip: PARENT S NAME: Maiden Name: of Birth: SS #: Home Phone: Address: City: Zip: Employer: Work #: Cell Phone: address: PARENT S NAME: of Birth: SS #: Home Phone: Cell Phone: Address: City: Zip: Employer: Work #: address: PRIMARY INSURANCE: Phone #: Member ID #: Group #: POLICY HOLDER NAME: of Birth: Policy Holder s SS #: Relationship to patient: LABORATORY PREFERENCE: QUEST OR LAB CORP (please circle one) PRIMARY PHARMACY: PHONE #: ADDRESS: CITY: ZIP: OFFICE POLICY: In an attempt to remain on schedule, we ask that you arrive on time. If you are more than 15 minutes late, you may be asked to reschedule. We ask that you call 24 hours prior to canceling or rescheduling. After 2 missed appointments without the required notice, a $25 charge will be assessed. By signing below, you agree to these terms. RESPONSIBLE PARTY SIGNATURE: Please verify all information contained above. If any changes need to be made, simply mark through the item and write in the correct information. Be signing below, patient/guarantor agrees the above information is correct. Authorization: I hereby authorize 18 and under MD to furnish information to insurance carriers concerning my healthcare illness/accident/well-routine care, and I hereby irrevocably assign to the doctor all payments for medical services rendered. I understand that I am financially responsible for all charges regardless of insurance coverage. Responsible Party Signature

3 Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations I,, (patient name) understand that as part of my healthcare, Debra A. Naylor, M.D., P.A. doing business as 18 and Under MD, originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as: - A basis for planning care and treatment, - A means of communication among the many healthcare professionals who contribute to patient care, - A source of information for applying diagnosis and treatment information to the bill, - A means by which a third-party-payer can verify that services billed were actually provided, and - A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals. I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges: - The right to review the notice prior to signing this consent, - The right to object to the use of my health information for directory purposes, and - the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations. I further understand that Debra A. Naylor, M.D., P.A., doing business as 18 and Under MD reserves the right to change their notice and practices and prior to implementation, in accordance with Section of the Code of Federal Regulations. Should Debra A. Naylor, M.D., P.A., doing business as 18 and Under MD change their notice, they will send a copy of any revised notice to the address I ve provided via US Mail or through in-person contact. I wish to have the following restrictions to the use or disclosure of my healthcare information : I wish to allow the following persons access to my medical information :. This person/persons may find out test results, medications and/or prescriptions and relay this information to me and/or pick it up for me. They may speak to this doctor s office for billing, treatment, appointments, etc.. I understand that no shot record or work/school excuses can be faxed. I understand that as part of this organization s treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax. I understand that Debra A. Naylor, M.D., P.A., doing business as 18 and Under MD is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section of the Code of Federal Regulations. I fully understand and accept / decline the terms of this consent. (please initial one.) Patient / Parent Signature, if patient is a minor Witness Acknowledgement of Review of Notice of Privacy Practices I have reviewed this office s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document. Patient / Parent Signature, if patient is a minor This document will expire one year from date form is signed, or when minor patient turns 18. A new document will need to be signed at the time either of the above mentioned conditions are met.

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6 Consent for Alternate Caregiver I, authorize the following person(s) to seek and obtain medical attention and medical information for my child(ren),. (Please list child(ren) by full names) Authorized Persons: (Parent s Name) () (Signature) Consent for Vaccination for Alternate Caregiver I, authorize the following person(s) to consent to and sign for vaccinations at the time of service in my absence. (Parent s Name) () (Signature)

7 Patient Name: Patient DOB: Patient Preference Regarding Communication of Health Information Authorized Persons I hereby give permission to 18 & Under MD to disclose and discuss any information related to my child(s) medical condition(s) with the following family member(s), other relative(s) and/or close personal friend(s): Name Name Name Relationship Relationship Relationship I do not wish to permission for additional family members, relatives or close personal friends to have access to any information regarding my child(s) medical condition(s). How to Consent I wish to be contacted in the following manner: Home Telephone: [ ] OK to leave message with detailed information [ ] OK to leave non critical lab results [ ] Leave message with call back number only Cell Phone: [ ] OK to leave message with detailed information [ ] OK to leave non critical lab results [ ] Leave message with call back number only Written Communication [ ] OK to send mail to my home address [ ] OK to send mail to my work/office address [ ] OK to fax to this number The duration of this authorization is indefinite unless otherwise revoked in writing. I understand that requests for medical information from persons not listed above will require a specific authorization prior to the disclosure of any information. Signature of Parent/Legal Guardian

8 Records Request I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that this authorization is voluntary. I understand that if the organization to receive this information is not a health plan or health care provider the information may no longer be protected by federal privacy regulations. Patient Name SSN of Birth Information Requesting: Immunization Records Problem List Labs and X-Rays Growth Charts All Organization Releasing Information: Physician s Name Name of Practice Address Phone Fax Organization Receiving Information: 18 & Under MD 3041 Churchill Dr. Ste. 300 Flower Mound, TX P: F: Signature Relationship to Patient

9 TEXAS DEPARTMENT OF STATE HEALTH SERVICES IMMUNIZATION REGISTRY (ImmTrac) MINOR CONSENT FORM (Please print clearly) Child s Last Name For Clinic/Office Use Child s First Name / / Child s of Birth *Children under 18 years only. Child s Middle Name Child s Gender: Male Female Child s Address Apartment # Telephone City State Zip Code County Mother s First Name Mother s Maiden Name ImmTrac, the Texas immunization registry, is a free service of the Texas Department of State Health Services (DSHS). The immunization registry is a secure and confidential service that consolidates and stores your child s (under 18 years of age) immunization records. With your consent, your child s immunization information will be included in ImmTrac. Doctors, public health departments, schools and other authorized professionals can access your child s immunization history to ensure that important vaccines are not missed. The Texas Department of State Health Services encourages your voluntary participation in the Texas immunization registry. Consent for Registration of Child and Release of Immunization Records to Authorized Entities I understand that, by granting the consent below, I am authorizing release of the child s immunization information to DSHS and I further understand that DSHS will include this information in the state s central immunization registry ( ImmTrac ). Once in ImmTrac, the child s immunization information may by law be accessed by: a public health district or local health department, for public health purposes within their areas of jurisdiction; a physician, or other health-care provider legally authorized to administer vaccines, for treating the child as a patient; a state agency having legal custody of the child; a Texas school or child-care facility in which the child is enrolled; a payor, currently authorized by the Texas Department of Insurance to operate in Texas, regarding coverage for the child. I understand that I may withdraw this consent to include information on my child in the ImmTrac Registry and my consent to release information from the Registry at any time by written communication to the Texas Department of State Health Services, ImmTrac Group MC 1946, P.O. Box , Austin, Texas By my signature below, I GRANT consent for registration. I wish to INCLUDE my child s information in the Texas immunization registry. Parent, legal guardian or managing conservator: Printed Name Signature Privacy Notification: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See for more information on Privacy Notification. (Reference: Government Code, Section , , and ) Upon completion, please fax or mail form to the DSHS ImmTrac Group or a registered Health-care provider. Questions? (800) (512) Fax: (866) Stock No. EC-7 Texas Department of State Health Services ImmTrac Group MC 1946 P.O. Box Austin, TX Revised 05/18/2012 PROVIDERS REGISTERED WITH ImmTrac Please enter client information in ImmTrac and affirm that consent has been granted. DO NOT fax to ImmTrac. Retain this form in your client s record.

10 DEPARTAMENTO ESTATAL DE SERVICIOS DE SALUD DE TEXAS REGISTRO DE INMUNIZACIÓN (ImmTrac) FORMULARIO DE CONSENTIMIENTO PARA MENORES (Favor de escribir claramente con letra de molde) Apellido del Niño(a) For Clinic/Office Use Nombre del Niño(a) / / Fecha de Nacimiento del Niño(a) *Solamente niños menores de 18 años. Segundo Nombre del Niño(a) Género: Masculino Femenino Dirección del Niño(a), Calle Apartamento # Teléfono Ciudad Estado Código Postal Municipio Nombre de la Madre Apellido de Soltera de la Madre ImmTrac, el registro de inmunización de Texas, es un servicio gratis que proporciona el Departamento Estatal de Servicios de Salud de Texas (DSHS). El registro de inmunización es un servicio seguro y confidencial que consolida y guarda el récord de inmunizaciones de su niño(a) (menor de 18 años de edad). Con su consentimiento, la información de la inmunización de su niño(a) será incluida en ImmTrac. Los doctores, departamentos de salud pública, escuelas y otros profesionales autorizados pueden tener acceso al historial de inmunización de su niño(a) para asegurar que las vacunas importantes no le falten. El Departamento Estatal de Servicios de Salud le anima a participar voluntariamente en el registro de inmunización de Texas. Consentimiento Para Registrar al Menor y Dar a Conocer los Documentos de Inmunización a las Entidades Autorizadas Entiendo que, con mi consentimiento a continuación, autorizo que se dé a conocer la información de inmunización del menor al DSHS, y además entiendo que el DSHS incluirá esta información en el registro central de inmunización del estado ( ImmTrac ). Una vez que la información del menor esté en ImmTrac, por ley la puede acceder: el distrito de salud pública o el departamento de salud local, para propósitos de salud pública dentro de sus áreas de jurisdicción; el médico, o algún otro médico o proveedor de atención de salud legalmente autorizado para administrar vacunas, en el tratamiento del menor como paciente; la agencia estatal que tenga la custodia legal del menor; la escuela o la guardería de Texas en que el menor esté inscrito; el pagador, actualmente autorizado por el Departamento del Seguro de Texas para operar en Texas, con respecto a la cobertura del menor. Entiendo que puedo retirar este consentimiento para incluir información sobre el menor en el Registro de ImmTrac y mi consentimiento para dar a conocer la información del registro en cualquier momento mediante comunicación escrita a Texas Department of State Health Services, ImmTrac Group MC 1946, P.O. Box , Austin, Texas Al firmar abajo, YO AUTORIZO el consentimiento para registrarlo. Deseo INCLUIR la información de mi niño(a) en el registro de inmunización de Texas. Alguno de los padres, tutor legal o administrador de bienes: Escriba con letra de molde Fecha Firma Notificación Sobre Privacidad: Tan solo por unas cuantas excepciones, usted tiene el derecho de solicitar y de ser informado sobre la información que el Estado de Texas reúne sobre usted. A usted se le debe conceder el derecho de recibir y revisar la información al requerirla. Usted también tiene el derecho de pedir que la agencia estatal corrija cualquier información que se ha determinado sea incorrecta. Diríjase a para más información sobre la Notificación sobre privacidad. (Referencia: Government Code, sección , , y ) Al rellenarlo, mándelo por fax o correo postal al Grupo ImmTrac del DSHS o a un proveedor de salud inscrito. Tiene preguntas? (800) (512) Fax: Fax: (866) Stock No. EC-7 Texas Department of State Health Services ImmTrac Group MC 1946 P.O. Box Austin, TX Revised 05/18/2012 PROVIDERS REGISTERED WITH ImmTrac Please enter client information in ImmTrac and affirm that consent has been granted. DO NOT fax to ImmTrac. Retain this form in your client s record.