Patient Information · I authorize The Pediatric Group of Southern California to treat my child. I...
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Patient Registration Patient Information Patient Name:_____________________________________________________ Sex: M F Date of Birth:______________________ Mother/Guardian:_______________________________________ Date of Birth:_______________ SS#:____________________________ Address:____________________________________________ City:_______________________ State:________ Zip:_______________ Home Phone:____________________________ Cell Phone:____________________________ Email:___________________________ Employer:_______________________________ Work Phone:___________________________ Occupation:______________________ Driver’s License:_________________________ May we contact you by Email/Text Message for appointment reminders? Yes No Father/Guardian:_______________________________________ Date of Birth:_______________ SS#:_____________________________ Address:____________________________________________ City:_______________________ State:________ Zip:_______________ Home Phone:____________________________ Cell Phone:____________________________ Email:___________________________ Employer:_______________________________ Work Phone:___________________________ Occupation:______________________ Driver’s License:_________________________ May we contact you by Email/Text Message for appointment reminders? Yes No Sibling Name:________________________________________________ Sex: M F Date of Birth:__________________________ Sibling Name:________________________________________________ Sex: M F Date of Birth:__________________________ Children live with: Mother Father Both Guardian_______________________________________________________________ Responsible party for payment of medical services: Mother Father Both Guardian__________________________________ Emergency Contact Person:___________________________________ Relationship:_________________ Phone:___________________ Referred to our office by:____________________________________________________________________________________________ Insurance Information Primary Insurance:___________________________________________ Claims Address:_______________________________________ Policy #:_____________________________________ Group #:________________________________ Copay: $___________________ Subscriber Name:______________________________________ Subscriber Date of Birth:_______________ Relationship:__________ Secondary Insurance:________________________________________ Claims Address:_______________________________________ Policy #:_____________________________________ Group #:________________________________ Copay: $___________________ Subscriber Name:______________________________________ Subscriber Date of Birth:_______________ Relationship:__________ I prefer to do my own insurance filing. Signature:______________________________________________ Date:____________________ Pharmacy Information Pharmacy Name:____________________________________________________ City:__________________________________________ Phone:___________________________________________________ Fax:____________________________________________________ Authorization of treatment assigned of benefit: I authorize The Pediatric Group of Southern California to treat my child. I further authorize the release of medical information necessary for the completion of insurance forms. I authorize payment directly to The Pediatric Group of Southern California for all medical or surgical benefits otherwise payable to me under the terms of my insurance. I understand that I am financially responsible for all co-payments and any charges not paid by my insurance. A photocopy of this authorization shall be considered as effective and valid as the original. Medical care or immunizations cannot be given unless my child is accompanied by one of the following: ________________________________________________________________________________________. I understand that if any child’s physician or any person employed by or under the direction and control of my child’s physician(s) is directly exposed to my child’s bodily fluids in any manner which may, according to the current guidelines for the Center for Disease Control, transmit the Human Immunodeficiency Virus (HIV) or Hepatitis B or C viruses, that I am deemed by law to have consented to testing for infection with HIV or Hepatitis B or C viruses. I further understand that by law I will have deemed to have consented to the release of these test results to the person who is exposed to my child’s bodily fluids. Parent/Guardian Signature:__________________________________ Relationship:_______________________ Date:________________ Witness’ Signature:_________________________________________ Date:_____________________________
Transcript of Patient Information · I authorize The Pediatric Group of Southern California to treat my child. I...
Patient Registration
Patient Information Patient Name:_____________________________________________________ Sex: � M � F Date of Birth:______________________
Mother/Guardian:_______________________________________ Date of Birth:_______________ SS#:____________________________
Address:____________________________________________ City:_______________________ State:________ Zip:_______________
Home Phone:____________________________ Cell Phone:____________________________ Email:___________________________
Employer:_______________________________ Work Phone:___________________________ Occupation:______________________
Driver’s License:_________________________ May we contact you by Email/Text Message for appointment reminders? �Yes �No
Father/Guardian:_______________________________________ Date of Birth:_______________ SS#:_____________________________
Address:____________________________________________ City:_______________________ State:________ Zip:_______________
Home Phone:____________________________ Cell Phone:____________________________ Email:___________________________
Employer:_______________________________ Work Phone:___________________________ Occupation:______________________
Driver’s License:_________________________ May we contact you by Email/Text Message for appointment reminders? �Yes �No
Sibling Name:________________________________________________ Sex: � M � F Date of Birth:__________________________
Sibling Name:________________________________________________ Sex: � M � F Date of Birth:__________________________
Children live with: � Mother � Father � Both � Guardian_______________________________________________________________
Responsible party for payment of medical services: � Mother � Father � Both � Guardian__________________________________
Emergency Contact Person:___________________________________ Relationship:_________________ Phone:___________________
Referred to our office by:____________________________________________________________________________________________ Insurance Information Primary Insurance:___________________________________________ Claims Address:_______________________________________
Policy #:_____________________________________ Group #:________________________________ Copay: $___________________
Subscriber Name:______________________________________ Subscriber Date of Birth:_______________ Relationship:__________
Secondary Insurance:________________________________________ Claims Address:_______________________________________
Policy #:_____________________________________ Group #:________________________________ Copay: $___________________
Subscriber Name:______________________________________ Subscriber Date of Birth:_______________ Relationship:__________
� I prefer to do my own insurance filing. Signature:______________________________________________ Date:____________________
Pharmacy Information Pharmacy Name:____________________________________________________ City:__________________________________________
Phone:___________________________________________________ Fax:____________________________________________________
Authorization of treatment assigned of benefit: I authorize The Pediatric Group of Southern California to treat my child. I further authorize the release of medical information necessary for the completion of insurance forms. I authorize payment directly to The Pediatric Group of Southern California for all medical or surgical benefits otherwise payable to me under the terms of my insurance. I understand that I am financially responsible for all co-payments and any charges not paid by my insurance. A photocopy of this authorization shall be considered as effective and valid as the original. Medical care or immunizations cannot be given unless my child is accompanied by one of the following: ________________________________________________________________________________________. I understand that if any child’s physician or any person employed by or under the direction and control of my child’s physician(s) is directly exposed to my child’s bodily fluids in any manner which may, according to the current guidelines for the Center for Disease Control, transmit the Human Immunodeficiency Virus (HIV) or Hepatitis B or C viruses, that I am deemed by law to have consented to testing for infection with HIV or Hepatitis B or C viruses. I further understand that by law I will have deemed to have consented to the release of these test results to the person who is exposed to my child’s bodily fluids. Parent/Guardian Signature:__________________________________ Relationship:_______________________ Date:________________
Witness’ Signature:_________________________________________ Date:_____________________________
Pediatric Medical History
Patient Information
Patient Name:___________________________________________________________ Date:________________________
Development Are you concerned about the patient’s… Physical development? � No � Yes ______________________________________________________________ Mental or Emotional development? � No � Yes ______________________________________________________________ Learning Ability? � No � Yes ______________________________________________________________ Attention Span or activity level? � No � Yes ______________________________________________________________ If in school, has the patient had… Tutoring outside of the classroom? � No � Yes ______________________________________________________________ Placement in a special class? � No � Yes ______________________________________________________________ To repeat a grade level? � No � Yes ______________________________________________________________ Educational or psychological testing? � No � Yes ______________________________________________________________ Behavioral Problems? � No � Yes ______________________________________________________________ Maternal and Newborn History Pregnancy: Check if the mother had any of the following problems:
� Excessive Weight Gain � Rubella � None
� Urinary Infections � Venereal Disease � Other:______________________________________________
� Excessive Swelling � Diabetes Disease ______________________________________________
� Toxemia � Hepatitis B
Did the mother use drugs or alcohol? � No � Yes ___________________________________________________________________
Was delivery difficult or complicated? � No � Yes _____________________________________________________________________
______________________________________________________________________________________________________________
Birth History
Birth Weight: _____________ Length: ____________ Apgar: ____________ Was born: � Term � Early � Late
If early, how many weeks gestation? ___________________ Was labor difficulty or prolonged? � Yes � No
Was delivery difficult or complicated? � No � Yes___________________________________________________________________
______________________________________________________________________________________________________________
Newborn History (Check if the patient had any of the following problems):
� None � Colic � Breastfeeding Issues
� Slow Weight Gain � Jaundice � Formula Feeding Issues
� Blood in Stools � Recurring Vomiting � Multiple Formula Changes
� Recurring Diarrhea � Feeding Problems � Other:_______________________________________
continued on page 2
Pediatric Medical History
Patient Information (continued from page one) Patient Name:___________________________________________________________ Date:________________________
Family History (Check if a family member has had any of the following): (Allow M=mother, F=father, S=sibling, GM=grandmother, GF=grandfather, A=aunt, U=uncle)
� ____Allergies � ____Emotional/Behavioral � ____Liver Disease � ____Anemia/Blood disorders � ____Epilepsy or convulsions � ____Mental Illness � ____Asthma � ____Eye or visual problems � ____Mental Retardation � ____Bladder/Kidney � ____Heart attack/stroke before 50 yrs. � ____Obesity � ____Cancer � ____Other Hearth problems � ____Respiratory infections � ____Deafness � ____Hereditary problems � ____Stomach/GI � ____Diabetes before 50 yrs. � ____High blood pressure before 50 yrs. � ____Thyroid/Endocrine problems � ____Drug allergies � ____High cholesterol � ____Tuberculosis � ____Drug/alcohol abuse � ____Immunity problems/HIV � ____Other____________________ � ____Ear Infections/PE Tubes � ____Learning problems/Attention span ________________________
Family Are patient’s mother and father: � Married � Separated � Divorced If separated or divorced, what is the patient’s custody status? _____________________________________________________________
______________________________________________________________________________________________________________
If one or both of the parents are not living at home, how often does the child see that parent(s)?__________________________________
______________________________________________________________________________________________________________
Are there siblings living away from home? � No � Yes (if yes, please state ages and where they are currently living):_______________
______________________________________________________________________________________________________________
Current Medical History
Is patient having any medical problems? � No � Yes (if yes, please explain):_______________________________________________
______________________________________________________________________________________________________________
Is patient generally in good health? � Yes � No (if no, please explain):____________________________________________________
______________________________________________________________________________________________________________
Are immunizations up to date? � Yes � No (if no, please explain):_______________________________________________________
______________________________________________________________________________________________________________
Please list current medications:_____________________________________________________________________________________
______________________________________________________________________________________________________________
Does patient have any drug allergies? � No � Yes (if yes, please list):____________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Has patient had any past surgeries? � No � Yes (if yes, please explain):__________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Are there any other concerns you have regarding your child? � No � Yes (if yes, please explain):_______________________________
______________________________________________________________________________________________________________
18370 Burbank Blvd. Suite 307 Tarzana CA 91356 Tel 818.996.6000 – 29525 Canwood St. Suite 250 Agoura Hills, CA 91301 Tel 818.735.5555 www.thepediatricgroup.net
CANCELLATIONPOLICY
Toproperlyaccommodateallourpatients,theofficerequires24-hournoticeforcancellations.
Patientswhodonotshowuptotheirscheduledappointmentorwhodonotprovidea24-hourcancellationnoticewillbechargedasfollows:
• $25.00 Office visit • $75.00 Physical Exam or New Patient Appointment • $100.00 Allergy Recheck • $150.00 Allergy Consultation or Allergy Summary
Feesmustbepaidpriortothepatients’nextvisit.Unpaidfeesexceedingthirtydaysmayincuranadditionalfee.Excessiveno-showsmayresultinadismissalfromthepractice.
PATIENTRESPONSIBILITY
Patientsareresponsibleforprovidingthisofficewithaccurateandcurrentinsurance,telephoneandaddressinformation.Are-billingfeeof$25.00maybechargedifadelayinpaymentresultsfromoutdatedorinaccurateinformation.
Bysigningthisform,IacknowledgethatIhavereadandunderstandtheinformationprintedabove.
Patientsname SignatureofPatientorParent/Guardian
Date PrintedName
18370 Burbank Blvd. Suite 307 Tarzana CA 91356 Tel 818.996.6000 – 29525 Canwood St. Suite 250 Agoura Hills, CA 91301 Tel 818.735.5555 www.thepediatricgroup.net
NoticeofPrivacyPracticesAcknowledgementForm
THENOTICEOFPRIVACYPRACTICEDESCRIBESHOWMEDICALINFORMATIONABOUTYOUMAYBEUSEDANDDISCLOSEDANDHOWYOUCANGETACCESSTOTHISINFORMATION.PLEASEREVIEWITCAREFULLY,ASITEXPLAINS:
• Howthisofficewilluseanddiscloseyourprotectedhealthinformation.• Yourprivacyrightswithregardtoyourprotectedhealthinformation.• Thisoffice’sobligationsconcerningtheuseanddisclosureofyourprotected
healthinformation.IacknowledgethatIhavereceivedacopyoftheofficeNoticeofPrivacyPractices.IfurtheracknowledgethattheofficeNoticeofPrivacyPracticesisavailableatthefrontdeskuponrequest.______________________________________________________________ ________________________PatientorPatientRepresentativeSignature Date______________________________________________________________PatientorPatientRepresentativePrintedName
About Telemedicine
WHAT IS TELEMEDICINE?
Telemedicine (also sometimes called telehealth) services are a way to deliver healthcare services locally to a patient when the healthcare provider is located at a distant site. Telemedicine is generally defined as the use of electronic information and communications technology to exchange medical information from one site to another site to provide medical or surgical treatment to a patient and/or to participate in the medical diagnosis of, or medical opinion or medical advice to, a patient.
When a healthcare provider believes a patient may benefit from the use of telemedicine services, telemedicine can maintain a continuity of care with the provider and facilitate patient self- management and caregiver support of the patient. Telemedicine services often provides a broader access to medical care, eliminates transportation concerns, and increases comfort and familiarity for patients and their families when located in their own homes or other local environments.
However, telemedicine uses new communications technology for which there is little research supporting its effectiveness. For example, telemedicine services may not be as complete as in- person healthcare services because the healthcare provider will not always be able to observe subtle non-verbal communications such as a patient's posture, facial expression, gestures, and tone of voice.
Telemedicine may transfer medical information through the use of interactive, real-time audio/visual technology (for example, video conferencing) or electronic data interchange (for example, computer-to-computer exchanges), or it may transfer medical information through the use of store-and-forward technology (for example, emails). While precautions are taken to secure the confidentiality of telemedicine services, the electronic transmission of medical information can be incomplete, lost or otherwise disrupted by technical failures. Additionally, despite such measures, the transmission and storage of medical information can be accessed by unauthorized persons, causing a breach of the patient's privacy.
I read and understand the information provided in this document. I discussed any question I had with my doctor and all of my questions were answered to my satisfaction.
__________________________ ____________________________________ Date Patient's Signature
Revised 7/2019
Consent to Use Telemedicine Patient’s Name_______________________ My Doctor’s Name_______________________ CONSENT TO USE TELEMEDICINE I am physically located in California. At the beginning of each telemedicine session, I will help my doctor to complete a check-in to assess the suitability of using telemedicine services by verifying my full name, my current location, my readiness to proceed, and whether I am in a situation conducive to private, uninterrupted communication. By signing this consent, I understand and agree:
1. My doctor is located in and licensed by the State of California. My doctor may not be able to prescribe medications for me and/or may not be able to assist me in an emergency situation when I am located in any other state or country. If I require medication, I may contact my doctor. If I require emergency care, I may call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for free 24-hour hotline support.
2. I submit to the exclusive jurisdiction of the California state superior courts and agree that
any claim, lawsuit, or other legal proceeding arising out of or relating to the telemedicine services provided by my doctor and my doctor’s staff will be brought solely and exclusively in California state superior courts. I also agree that the interpretation of this consent will be exclusively governed by and construed in accordance with the laws of California.
3. My doctor believes that telemedicine services are appropriate for my medical condition
and that I would benefit from its use despite its risks and limitations. While I may expect anticipated benefits from the use of telemedicine, no specific results can be guaranteed or assured.
4. If my doctor believes at any time that another form of services (for example, a traditional
in-person consultation) would be appropriate, my doctor may discontinue telemedicine services and schedule an in-person consultation with my doctor or refer me to a healthcare provider in my area who can provide such services.
5. I have the right to withdraw consent to the use of telemedicine services at any time and
receive inperson healthcare services with my doctor.
6. I received an explanation of how the electronic communications technology will be used for the telemedicine services. I am comfortable with using electronic communications technology to communicate with my doctor and understand there are limitations to the technology which may require an in-person consultation.
7. I agree to have the necessary computer, equipment and internet access for my
telemedicine communications. I also agree to arrange for a location with sufficient lighting and privacy and is free from distractions and intrusions during my telemedicine communications.
8. The laws that protect privacy and the confidentiality of my medical information also apply to telemedicine. The medical information that is transmitted electronically by my doctor to me will be encrypted during transmission and will be stored only by my doctor or a service provider selected by my doctor. I understand the dissemination of any personally-identifiable images or information from the telemedicine communication to researchers or other healthcare providers will not occur except as required by federal or California state law.
9. I understand my risks of a privacy violation increase substantially when I enter
information on a public access computer, use a computer that is on a shared network, allow a computer to “auto remember” usernames and passwords, or use my work computer for personal communications. I also understand it is my responsibility to encrypt medical information I transmit electronically to my doctor and my failure to use technical safeguards, such as encryption, increases my risks of a privacy violation.
10. [I agree to be videotaped and recorded during the telemedicine services. I understand the
resulting images and audio will become part of my medical record.] OR [No part of the encounter will be recorded without my written consent.]
11. I have the right to access my medical information and obtain copies of my medical
records in accordance with California law.
12. I understand that the telemedicine services provided to me will be billed to my health insurance company and that I will be billed for any patient responsibility as per my insurance.
I read and understand the information provided in this Consent to Use of Telemedicine. I discussed any questions I had with my doctor and all of my questions were answered to my satisfaction. ______________________ ______________________________ Date Patient’s Signature
