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NEW PATIENT REGISTRATION

Registration DocumentsMichael Linck2017-01-23T11:46:48+00:00

Step 1 of 10 - PATIENT INFORMATION

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How many children are you registering?*
- 1
- 2
- 3
- 4
- 5
- 6
Patient 1 Name*
First Last
Patient 1 Date of Birth*
MM
DD
YYYY
Patient 1 Gender*
- Female
- Male
Patient 2 Name*
First Last
Patient 2 Date of Birth*
Patient 2 Gender*
- Female
- Male
Patient 3 Name*
First Last
Patient 3 Date of Birth*
Patient 3 Gender*
- Female
- Male
Patient 4 Name*
First Last
Patient 4 Date of Birth*
Patient 4 Gender*
- Female
- Male
Patient 5 Name*
First Last
Patient 5 Date of Birth*
Patient 5 Gender*
- Female
- Male
Patient 6 Name*
First Last
Patient 6 Date of Birth*
Patient 6 Gender*
- Female
- Male

Mailing Address*
Street Address Address Line 2 City State ZIP Code

Consent for Medical Treatment*
- There are no court orders now in effect that prohibits me from signing this consent. I do hereby request and authorize the doctor(s) and practice staff of Pediatric People PLLC to perform ALL necessary medical care for my child(ren). I understand that all medical treatments contain inherent risks.
Will you allow anyone (besides you or your spouse) to bring your child(ren) to Pediatric People for treatment?*
- Yes, I do authorize and consent to Pediatric People PLLC to provide medical treatment to my child without my presence.
- No, the above mentioned child(ren) will be accompanied to the office by their parents or legal guardian for all medical treatment.
How many individuals would you like to authorize to accompany your child for medical treatment without your presence?*
- 1
- 2
- 3
- 4
Authorized Individual*
First Last
Authorized Individual*
First Last
Authorized Individual*
First Last
Authorized Individual*
First Last

Financial Policy & Assignment of Benefits*
- I understand that insurance co-payments, deductible, self-payment or outstanding balances are due before your child’s visit. We may refuse service if you have any unpaid balance.
  
  I hereby assign to Pediatric People PLLC all insurance benefits, if any, otherwise payable to me for services rendered to myself and/or my dependent(s), and I hereby authorize and direct my insurance carrier to issue payment of such benefits directly to Pediatric People, PLLC. I authorize the use of my signature, and a copy thereof, on the insurance submissions.

Some Charges May NOT be Covered by Insurance*
- I understand that some procedures and services may not be covered by my insurance policy. I agree to pay all charges, in full, once they have been processed by my insurance company, if any balance remains due. Below are the most common procedures and tests that may be applied toward your insurance deductible. These costs are approximate and will vary based on your insurance company. These charges are in addition to the office visit charge.
  
  - Earwax Removal $65 - $75
  - Lesion/Wart Destruction $125 - $175
  - Sutures, Staples or Skin Glue $125 - $225
  - Abscess Care $150 - $180
  - X-rays & Radiologist $25 - $39
  - Splinting $50 - $95
  - Breathing Capacity Test $19
  - Flu Test A $15
  - Flu Test B $15
  - Strep Test $15
  - RSV Test $9
  - Mono Test $7

How can we communicate with you?*
- I authorize Pediatric People, PLLC to communicate with me via the methods below. I understand that this authorization allows Pediatric People, PLLC to leave a message or send an email regarding test results, appointments, referrals, or other information regarding your child’s care.
Phone/Voice Mail 1*
Email 1*
Enter Email Confirm Email
Phone/Voice Mail 2 (optional)
Email 2 (optional)
Enter Email Confirm Email

Notice of Privacy Practices*
- I have reviewed Pediatric People PLLC's Notice of Privacy Practices dated October 1, 2013. I understand that I may receive a printed copy of this notice upon verbal or written request now or in the future. The notice may also be viewed on our website at PediatricPeople.com.

Immunization Certification*
- Yes, I immunize my child according to the immunization schedule established by the Centers for Disease Control and Prevention. I certify that my child is current with all immunizations.
- No, I do NOT immunize my child according to the immunization schedule established by the Centers for Disease Control and Prevention.
- No, I do NOT immunize my child according to the immunization schedule established by the Centers for Disease Control and Prevention, but I agree to catch-up and follow the immunization schedule established by the Centers for Disease Control and Prevention at my child’s first visit with Pediatric People, PLLC.
STOP! Non-immunized individuals pose a health risk to newborn children because newborns are unable to receive immunizations until 2 months of age. Please ask for assistance before proceeding.

Missed Appointments*
- I understand that I will be charged $75 if I fail to cancel an appointment before the scheduled time.
Arriving Late to an Appointment*
- I understand that if I arrive more than 10 minutes late, my appointment WILL be rescheduled. Medical emergencies are the ONLY exception to this rule.
Online Patient Portal Secure Messaging Feature*
- I understand that this service is not for medical situations requiring a quick response and I can expect up to a 48-hour response time.
After-hours Nurse Line*
- I understand to use the after hours nurse service is $15 per call.
Telephone Recordings*
- I understand that Pediatric People PLLC may record inbound and outbound telephone calls.
Credit Card Payments*
- I understand that I must keep a valid credit card on file. I authorize Pediatric People PLLC to charge my credit card for any amount not covered by my insurance company.
Form Completion Without a Visit*
- I understand that my physician will complete forms and prescription refills during my visit, at no charge. All forms requiring medical review and a physician's signature without a visit, will incur the following charges:
  
  - FMLA, Disability or Complex Forms - $29
  - Asthma Action Plans - $19
  - Allergy Plans - $19
  - Sports Physical Forms - $19
  - Day Care/School Attendance Forms - $9

Mother's (or Legal Guardian's) Name*
First Last
Father's (or Legal Guardian's) Name*
First Last
I would like access to the Patient Portal so I may access my child's medical records, send secure messages, request prescription refills, view documents, etc.*
- Yes
- No
Portal Password*
(Must be between 8-20 characters.)
Confirm Portal Password*
Choose a portal security question.*
Portal Security Answer*
Signature of Parent or Legal Guardian*
How did you hear about us?*
- Word-of-mouth
- Sibling of Current Patient
- Internet
- Direct Mail
- Drive-by
- Insurance Website
- Internet Search
- Referred by Physician
- YELP
- Facebook

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