V3– 10/24/2018

Pediatric Family Registration Form New Patient Edit Information Today’s Date: ________

Patient Information

Child #1 Last Name _______________________________________________First_________________________________________MI ________ Date of Birth ___________________________ Sex: M F Unknown Social Security Number: ______________________ Child #2 Last Name _______________________________________________First_________________________________________MI ________ Date of Birth ____________________________ Sex: M F Unknown Social Security Number: ______________________ Child #3 Last Name _______________________________________________First_________________________________________MI ________ Date of Birth ____________________________ Sex: M F Unknown Social Security Number: ______________________ Child #4 Last Name _______________________________________________First_________________________________________MI ________ Date of Birth ____________________________ Sex: M F Unknown Social Security Number: ______________________ Ethnicity: (Data is used for statistical reporting.) Race: (Data is used for statistical reporting.) Central/S Am Cuban Hispanic or Latino Not Hispanic or Latino American Indian Asian African American White Mexican Puerto Rican Patient Refused Other _____________ Native Hawaiian/Pacific Islander Unknown Patient

Refused

Religion: ____________________________ Preferred Language: English Spanish Other Need Interpreter? YES NO Comments: ___________________ Hearing Impaired? YES NO Comments: ___________________ Vision Impaired? YES NO Comments: ___________________

Patients’ Primary Address

Address: _______________________________________________________ City, State, Zip: _______________ County: _______________________________________________________ Country: ___________________________________________ Preferred Method of Contact: Home Cell Work Home Phone: ( ) Alt Phone Letter Email Cell Phone: ( ) Automated Reminder Calls/Text about Appointment YES NO Work Phone: ( )

Alt Phone: ( )

E-Mail: _______ No Email Patient Refuses to give email

Patients’ Parental Information

Patient lives with Both Parents Mom Dad Guardian Other (please explain: _____________________________) Custody Agreement YES NO N/A (If YES, please provide copy)

Parent’s Name: _____________________________________ Parent’s Name: ______________________________ Parent Address same as patient YES NO Parent Address same as patient YES NO If NO- please complete If NO- please complete Addr1: ___________________________________________________ Addr1: _____________________________________________ Addr2: ___________________________________________________ Addr2: _____________________________________________ City, State, Zip: _____ City, State, Zip: ________ Home phone: Home phone: Cell Phone: Cell Phone: Email Address: Email Address: Preferred Method of Contact: Preferred Method of Contact: Alt Phone Number Email Letter Alt Phone Number Email Letter Phone Call (Cell) Phone Call (Home Phone Call (Cell) Phone Call (Home) Employment Status: Employment Status: Employed FT Employed PT Homemaker Disabled Employed FT Employed PT Homemaker Disabled Unemployed Active Military Retired Other Unemployed Active Military Retired Other Employer: Employer:

V3– 10/24/2018

Primary Pharmacy Name, Address & Phone #:

Insurance Information – Please provide a copy of the card

PRIMARY CARRIER: Telephone #: ( ) Address: Child’s ID: Subscriber’s Name: Group/Plan#: Effective Date: Subscriber’s DOB: Sex: M F Unknown Subscriber SS#: Patient Relationship to Insured: PCP listed on Card:

Guarantor Information (Guarantor is the person financially responsible for this patient’s bill.)

Guarantor: Patient’s Relationship to Guarantor: Addr1: Social Security Number: Addr2: Date of Birth: Sex: M F Unknown City, State, Zip: Home Phone: ( ) Employer: Work Phone: ( ) Address: Cell Phone: ( ) City, State, Zip: Email Address:

Emergency Contact Information (Someone living outside the primary household)

Last Name, First Name: Patient’s Relationship to Contact: Addr1: Home Phone: ( ) Addr2: Work Phone: ( ) City, State, Zip: Cell Phone: ( ) Assignment of Benefits/Authorization/Notice of Collection Action

I understand I am responsible for knowing the benefits my insurance plan provides. In doing so, it is also my responsibility to verify proof of insurance by ensuring that the office staff has the most current/valid insurance card on file. I further understand that all co‐payments are due at time of service and I am also responsible to pay other amounts due; these amounts may include annual deductibles, charges denied by my insurance company as not covered or not medically necessary, and/or any fees incurred should my account require collection action. (E.G. late fees, collection agency, court or attorney costs). Also, please be advised our office may contact you via an automated system regarding appointments and/or account status. I agree this authorization shall remain valid unless/until I rescind in writing. (Please see the Primary Care Partners Payment Policy and Notice of Privacy Practices for more information) Signature__________________________________________ Date________________________________________

Care Center Name:____________________________________

Authorization to Bring a Minor

This authorization form is to be used when someone other than the parent or legal guardian will be bringing a

minor to the physician’s office.

Please check off all that apply

Child’s Name Date of Birth Evaluation Treatment Admin of Vaccines

I hereby provide permission for the following person to bring my child(ren) to the office for the services that I have

checked off above.

Name Relationship to Child (ren) Expiration Date

I understand that when the person(s) identified above take my child to Primary Care Partners,

_____________________________(Care Center Name) for a medical problem, my child(ren)’s protected health

information that the medical provider determines relevant to the office visit may be disclosed to this person.

I understand that when the person(s) identified above takes my child(ren) for a well visit or for treatment of a

medical problem, that this person may need to consent for my child(ren) to receive medical services that the

medical provider determines necessary for the care and treatment of my child(ren). I hereby authorize the

person(s) listed above to provide consent for the provision of the medical services stated above to my child(ren) by

the Medical Providers of Primary Care Partners, _______________________________(Care Center Name).

__________________________________________ ______________________________ Name of Parent/Legal Guardian Signature

__________________________________________ ______________________________ Relationship to Child(ren) Date

This authorization shall be valid for each visit that the person(s) identified above takes your child(ren) to Primary Care Partners, ____________________________________, office unless you provide an expiration date OR written notice of revoking authorization to the Primary Care Partners Care Center list above.

Initials

V2 10/2018

Consent for Treatment, Payment and Healthcare Operations

This form cannot be modified. Any handwritten changes to this form shall not be legally binding or enforceable

General Consent, Authorization, Patient Rights and Responsibilities I authorize Primary Care Partners (“PCP’), PCP care center)_____________________________PCP staff and physician(s) participating in my care to render medical care for my condition, which may include routine diagnostic procedures and such other medical treatment as may be deemed advisable by the physician(s) participating in my care. I acknowledge that no guarantees have been made to me about the outcome of my medical care and treatment. I understand the doctors in training, medical and nursing students, and paramedical personnel may observe and participate in my care under the supervision of PCP staff and my Physician(s). I authorize PCP (care center) -__________________________________ to arrange for the disposition of all specimens and tissues. I understand that it may be necessary for my healthcare provider(s) to take photograph, films, recordings and/or other like images and that the presence of a vendor representative may be required for medical, educational and /or continuity of care purposes. I hereby acknowledge receipt of a Statement of Patient Rights and Responsibilities. I understand that professional personnel are available to explain the statement.

Financial Arrangements I understand that I am financially responsible for the payment of my physician fees and these fees may not be covered by my insurance plan. I authorize payment of medical insurance benefits (including managed care, Medicare and Medicaid, when applicable) directly to any physician(s) participating in my care. I understand that some insurances and managed care entities require pre-approval of certain hospitalizations, procedure, and surgeries, and it may be my responsibility to obtain appropriate approvals. In addition, a deposit may be requested if I have been classified as a self-pay patient. I authorize PCP , and all the clinical providers who have providers who have provided care to me , along with any billing services , collection agencies , attorneys or other agents who may work on their behalf , to contact me on my cell phone, and/or home phone using automatic telephone dialing system or other computer assisted technology.

□ I do not authorize such contact at this time.

Protected Health Information I have received a copy of the Notice of Privacy Practices for Protected Health Information. This notice provides a complete description of the uses and disclosures of my Personal Protected Health Information (“PHI”). I have had an opportunity to review this information before signing this form. I consent to Primary Care Partners and providers participating in my care releasing my PHI (either in writing or verbally) in order to carry out treatment, payment, or healthcare operations. This includes any medical information (including drug and alcohol abuse treatment information, psychiatric treatment information, and HIV related information including HIV testing results (if applicable) , which may be needed to process claims for medical insurance (or managed care) benefits relative to physician visits, or which may be needed to conduct continued care planning.

Authorization to Draw Blood In the event that any individual participating in my care is accidentally exposed to my blood or bodily fluids. I authorize PCP to draw my blood

and test it for the presence of blood borne pathogens such as Human Immunodeficiency Virus (“HIV”). I understand that if such testing is

necessary that PCP or my physician will make all reasonable efforts to notify me. I consent to the confidential disclosure of the test results to

the authorized medical provider treating the person exposed to my blood or bodily fluids, so that the appropriate treatment determinations

may be made.

□ I decline to be tested for HIV and refuse the disclosure of my blood results.

Print Patient Name: __________________________________Medical Record #_______________________________

____________________________________________________________________________________ (am) (pm)

Signature of Patient Date Time I am signing on behalf of the patient. I recognize that signing on behalf of the patient is not acceptance of financial responsibility which I would

not otherwise have for services rendered.

______________________________________________________________________________ (am) (pm) Signature of Person Signing on behalf of Patient Date Time

_________________________________________________________________________________ Printed Name of Person Signing on behalf of Patient Relationship

Patient unable to sign because____________________________________________________________________________________

_________________________________________________________________________________ Signature of Witness (PCP Employee) Date Time

HIPAA Acknowledgement & Release Form Patient under 18 years old

Notice of Privacy Practices

Print Name of Patient __________________________________ Date of Birth ____________

Print Name of Parent/Guardian___________________________________________________

We, at Primary Care Partners, are required by law to maintain the privacy of and provide individuals

with access to the Notice of our legal duties and privacy practices with respect to protected health

information. I hereby acknowledge that I have reviewed the HIPAA Notice of Privacy Practice document

and understand that I may obtain a copy for my records upon request.

Release of Information

Please let us know how your child’s personal health information may be released

I am the only one who should receive information regarding my child’s personal health information.

Best way to contact me

Home phone ____________________________ Permission to leave a message Y N

Cell Phone ______________________________ Permission to leave a message Y N

I, _________________________, authorize the release of my child’s medical information including

diagnosis, records, examination rendered to my child and claims information. This information may be

released to:

_______________________________________

_____________________________________

________________________________________

Signed: _______________________________________ Date ________________________

Witness: ______________________________________ Date ________________________

V2 10/24/18

I, _______________________________________________, have received a copy of the

Skylands Pediatrics vaccine policy.

Child/Children’s name(s):

_____________________________DOB: ___________

_____________________________DOB: ___________

_____________________________DOB: ___________

Signature Parent/Guardian: _____________________________________________

Date: ______________

Signature of Witness: ___________________________________________________

Date: ______________

Skylands Pediatrics Vaccine Policy

For the past many years our doctors and nurse practitioner have done our best to support

families who are concerned about vaccinating their children. However, recent events have

caused us to re-evaluate our policy regarding unvaccinated or under-vaccinated children using

our practice for health care. Around the country, the actions of relatively few parents have put

many of the most vulnerable at risk. Whooping cough and measles are now in full resurgence.

These diseases are life threatening, especially to our youngest patients. In the face of recent

outbreaks, we no longer have the option of supporting families who choose not to vaccinate or

to delay recommended vaccines. It is our duty to provide the safest environment possible to

receive health care.

Effective June 1, 2019, our practice will not accept new families that do not vaccinate their

children. Established patients that are behind on their required vaccines will be required to

bring their children up to date and will be given one month to comply with our policy after

notification.

At Skylands Pediatrics:

We firmly believe in the safety and effectiveness of vaccines to prevent serious illness.

We firmly believe that all children should receive all of the recommended vaccines

according to the schedule published by the Advisory Committee on Immunization

Practices (ACIP) of the US Centers for Disease Control and Prevention (CDC) and the

American Academy of Pediatrics (AAP). (http://www.cdc.gov/vaccines/acip)

(http://www2.aap.org/immunization/izschedule.html)

We firmly believe based on all available literature, evidence and current studies, that

vaccines do not cause autism or other development disabilities.

All children must receive all vaccines recommended by the AAP and mandated by the

State of NJ and the State of PA.

Children who have not had the MMR vaccine and are over 1 year of age, must have this

done at first vaccine visit.

Children will need to come in at 1-4 week intervals (depending upon how many vaccines

they elect to receive at each visit) until they have caught up.

Parents or caregivers who choose not to comply with Skylands Pediatrics Vaccine Policy,

will be given a 1 month grace period after notification in order to find another pediatric

practice to care for their child.

We prefer to remain your child’s pediatrician and will not dismiss any family who is actively

working to properly vaccinate their child.