Ivy Pediatrics, PA - dr. rita pediatrics, pc

Ivy Pediatrics, PA - dr. rita pediatrics, pc

DR. RITA PEDIATRICS, P.C
Patient Information
Patient’s Name____________________________________ Social Security # ___________________ Sex (M/F)
Address __________________________________________ Home Phone (____) ____________DOB ________
City ___________________________
State _______
Zip ____________ E-Mail ____________________
List Sibling Names & DOB _____________________________________________________________________
Pharmacy name and address ____________________________________________________________________
Language: English________ Spanish________ Other_________
Race: Caucasian/White______ African American/Black ________ Hispanic _______ Asian _______
Native American_____ Native Hawaiian/other Pacific Islander________ Other _________
Ethnicity: Latino/Hispanic____ Other____ Not Reported/Refused _________
Parent (Guardian) Information
Mother’s First Name_____________________ Last Name _______________________ DOB _______________
Social Security # _______________________ Home Phone (____) ____________Cell Phone (____) __________
Employer Name _______________________ Work Phone (____) _____________________________________
Employer Address ____________________________________________________________________________
Father’s First Name_____________________ Last Name __________________________ DOB _____________
Social Security # _______________________ Home Phone (____) ____________Cell Phone (____) __________
Employer Name _______________________ Work Phone (____) _____________________________________
Employer Address ____________________________________________________________________________
Guardian’s Name _______________________ Relationship to Patient ____________________ DOB _________
Social Security # ________________________Home Phone (____) ____________Cell Phone (____) __________
Employer Name _______________________ Work Phone (____) _____________________________________
Employer Address ____________________________________________________________________________
Emergency Contact:
(in the event the parent(s) cannot be reached)
Contact Name _______________________ Relationship _____________ Phone # (____) _____________
Primary Insurance (Person who holds insurance)
Insurance Company ______________________ ID # ________________ Group Name or # __________________
Policy Effective Date _____________________ Copay Amount: ________________________________________
Insured’s Name ________________________________ Social Security # _________________ DOB __________
Relationship to Patient __________________________________________________________________________
Secondary Insurance (If child has multiple insurance coverage)
Insurance Company ______________________ ID # ________________ Group Name or # __________________
Policy Effective Date _____________________ Copay Amount: ________________________________________
Insured’s Name ________________________________ Social Security # _________________ DOB __________
Relationship to Patient __________________________________________________________________________
Dr. Rita Pediatrics, P.C. Financial Policy
The following is a statement of our Financial Policy, which we require you to read and sign prior to seeing the doctor.


FULL PAYMENT IS DUE AT TIME OF SERVICE. WE RUN A ZERO BALANCE OFFICE.
WE ACCEPT cash, check, and credit cards including Visa, MasterCard, and Discover.
Regarding Insurance:
Your insurance policy is a contract between you and your insurance company. Please be aware that some or perhaps all, of
the service provided may be non-covered services and considered unreasonable or unnecessary under the medical insurance.
In such case, the parent or responsible party will be accountable for the full payment of the bill.
Co-Pay/No-show Policy:
All co-pays and deductibles are due prior to treatment. If the child needs to be seen for multiple visits a co-pay is due for each
visit. It is against the law to waive co-pays. We will not waive the co-pay fee for multiple visits.
We require 24 hour notice of cancellation of all appointments. No-shows without prior cancellation are subject to a $25.00
fee. The parent, guardian or responsible party of the minor is responsible for the co-pay.
Interest:
We reserve the right to charge interest in the amount of 1.5% as provided by state law for unpaid balances. Balances over 90
days old will be referred to collection accounts and our service will be withdrawn.
Transfers:
In case of transfers, you are entitled to a free copy of your record. If you require your record to be mailed, a fee of $10.00 will
be charged.
Insurance Assignment & Release of Information
 I authorize Dr. Rita Pediatrics, P.C. to release any of my child’s medical information necessary to process
insurance claims.
 I authorize the release of payment of medical benefits to Dr. Rita Pediatrics, P.C., as my child’s provider.
 I understand that I am financially responsible for any deductible, co-insurance fees and charges for non-covered
services.
 Unless I am a member of an insurance organization of whom Dr. Rita Pediatrics, P.C. is a contracted provider of, all
charges are due at the time that services are rendered.
Thank you for understanding Dr. Rita Pediatrics, P.C. Financial policy. Please let us know if you have any questions or
concerns.
By signing this document the parent or responsible party agrees to have read, understood and agreed to the terms of the
policy.
_____________________________________
Signature of Parent or Responsible Party
____________________
Date
Patient Medical History (Historial médico)
Patient Name (Nombre) ____________________DOB (Fecha de Nacimiento) ______________
Pregnancy & Birth (Embarazo y Nacimiento)
Mother’s age at pregnancy (Edad de la madre durante el embarazo) _______________________
Any medical problems during pregnancy (Algún problema médico durante el embarazo?)
______________________________________________________________________________
Medications during pregnancy -exclude vitamins and iron (Medicinas durante el embarazo excluyendo vitaminas e hierro) ____________________________________________
Smoking, Alcohol, Non-Prescription drugs during pregnancy (Fumó, tomó alcohol, usó
medicamentos sin receta durante el embarazo) ________________________________________
Birth Hospital (Hospital donde nació) ___________ Obstetrician (obstetra) ________________
Was baby full term (Fue bebé a término)?
Y
N
Premature (Prematuro)?
Y
N
Delivery by (Tipo de Parto?):_______Vaginal birth ______ Cesarian. Apgar ______________
Birth Weight (Peso al nacer) __________ Discharge weight (Peso de alta)__________________
Length(Longitud) ___________
Blood Type (Tipo de sangre) ________________________
Delivery Complications (Complicaciones del parto)? ___________________________________
Problems with baby at birth (Problemas con el bebé al nacer?) ___________________________
Medications/Vitamins taken on a regular basis (Las medicinas/vitaminas tomadas con
regularidad)___________________________________________________________________
Hospitalizations/Operations (dates) (Hospitalizaciones/operaciones (fechas)
_____________________________________________________________________________
Serious Injuries/Fractures (include dates) (Heridas/Fracturas graves (incluya las fechas)
_____________________________________________________________________________
Allergies (Alergias)
Please list all allergies (Por favor enumere todas las alergias)
No known allergies (No alergias) _____
Seasonal/Environmental (Estacional/Ambiental) ______________________________________
Medication (Medicamento) _______________________________________________________
Food (Comida) _________________________________________________________________
Other (Otro) ___________________________________________________________________
Feeding & Nutrition (Alimentación & nutrición)
Appetite usually good (Apetito suele ser bueno)
Y
N
__________________________________
Colic/feeding problems in first 3 months? (¿Cólico/problemas de alimentación en los primeros 3 meses?)
Y
N _____________________________________________________________________________
Breast Feeding? (¿Lactancia materna?)
Y
N
Formula Feeding?(Alimentación con formula)
Until what age (Hasta qué edad)________________
Y
N
Current Brand(Marca)___________________
Special Diet (Dieta especial) _____________________________________________________________
Development & Behavior (Desarrollo & Conducta)
Age at which the child… (Edad a la que el niño):
Used Sentences (Usó oraciones) ____________________ Sat Alone (Se sentó solo)_________________
Walked Alone (Camino solo) _______________________Toilet Trained (USO el baño)
________________
Attending School? (¿Asiste a la escuela?)
Y
Problems in school (Problema en la escuela)
Learning problems (Problemas de aprendizaje)
N
Y
N
Y
Behavior problems (Problemas de comportamiento)
Bedwetting (Se orina en la cama)
Y
N
Grade (Grado) ____________________________
_____________________________________
N ____________________________________
Y N
_________________________________
Sleep problems (Problemas del sueño)
Y
N
Past Medical History (Historial médico pasado)
Has the child had any of the following diseases (Ha tenido el niño/a cualquiera de las enfermedades
siguientes):
___ Rubeola (Sarampión)
___ Hepatitis
___ Mumps (Paperas)
___ Seizures (Convulsiones)
___ Chickenpox (Varicela)
___ Pneumonia (Pulmonía)
___ Scarlet Fever (Escarlatina)
___ Anemia
___ TB Tuberculosis
___ Allergies
___ Urinary Infections (infecciones urinarias)
___ Eczema
___ Lyme’s (Enfermedad de Lyme)
___ Developmental Disorders
___ Meningitis
___ Rubella (German measles)
___ Ear Infection (infecciones de oído)
___ Strep Throat (infección de garganta por estreptococo)
___ Hives (Ronchas)
___ Heart Murmur (Soplo en el corazón)
___ Bedwetting Problems (Se orina en la cama)
(Sarampión Alemán)
Family Medical History (Antecedente medico familiar)
List blood relatives of child who’ve had the following problems – use abbrev.
(Lista de parientes del niño que han tenido los siguientes problemas- use abreviaciones)
M : Mother (Madre)
F : Father (Padre)
B : Brother (Hermano)
S : Sister (Hermana)
A : Aunt (Tia)
C : Cousin (Primo)
FM : Father’s Mother (Madre del padre)
FF : Father’s Father (Padre del padre)
MM : Mother’s Mother (Madre de la madre)
MF : Mother’s Father (Padre de la madre)
U : Uncle (Tio)
___ Cancer
___ Developmental Disorders (Trastornos del Desarrollo)
___ Diabetes
___ Heart Disease (Enfermedad del corazón)
___ HIV/AIDS (SIDA)
___ Anemia/Blood Disorder (Condición de la sangre)
___ Asthma (Asma)
___ Cholesterol Problems (Problema de colesterol)
___ Arthritis (Artritis)
___ Cystic Fibrosis (Enfermedad fibroquística de los pulmones)
___ Tuberculosis
___ Early Deafness (Sordo a temprana edad)
___ Alcoholism (Alcoholismo)
___ Birth Defects (Defectos de nacimiento)
___ Migraine (migraña)
___ Epilepsy/Seizures (Epilepsia/Convulsiones)
___ Drugs addiction (Drogadicción)
___ High Blood Pressure (Presión Alta)
Family Profile (Perfil de la familia)
Parents (Padres): ___ Married (Casados):
___ Seperated (Separados)
___ Divorced (Divorciados)
___ Other (Otro)
Number of people in household (Número de personas en el hogar) _________
Smokers in household? (Fumadores en el hogar) ______________________________________
Use Street Drugs? (Uso de drogas de la calle en el hogar?) ______________________________
Abuse Alcohol (Abuso de alcohol) _________________ Pets (Mascotas)___________________
With whom does the child reside with (Con quien vive el Niño/a) _________________________
By signing below I ACKNOWLEDGE RECEIPT OF DR. RITA PEDIATRICS, P.C.’S NOTICE OF
PRIVACY PRACTICES-separate form. (Al firmar abajo RECONOZCO HABER RECIBIDO UNA
COPIA DE LA POLÍTICA DE PRACTICA DE PRIVACIDAD DE DR. RITA PEDIATRICS,P.C.):
Child Name (Nombre del niño/a) __________________________________________________
Child DOB (Fecha de nacimiento):_________________________________________________
Name of person completing the form (Nombre de la persona que llena el formulario)
_____________________________________________________________________________
Relationship (Relación con el niño/a) _______________________________________________
Signature (firma)_______________________________________
Date(fecha)________________________
Telephone release of medical records (Divulgación de records médicos por teléfono):
Protecting your child’s privacy is very important to us. According to federal regulations we may not
discuss or release medical records information to anyone but the child’s parents or legal guardians unless
the parent or legal guardian authorizes Dr. Rita Pediatrics, P.C. to do so. Please complete the information
below to provide such authorization.
Proteger la privacidad de su hijo/a es muy importante para nosotros. De acuerdo con las regulaciones
federales solo podremos discutir o informar sobre records médicos del niño/a a los padres o guardianes
legales del mismo, a menos, que usted autorice a Dr. Rita Pediatrics, P.C. a compartir la información del
niño/a con otras personas o instituciones. Por favor complete la siguiente información para otorgarnos
dicha autorización.
I give permission to Dr. Rita Pediatrics, P.C. to: (yo doy permiso a Dr. Rita Pediatrics, P.C. para:) (Check
all that apply)(Marque todas las que apliquen)
___ Telephone my home: (Llamar por teléfono a mí casa)
___ Telephone my work: (Llamar por teléfono a mi trabajo)
___ Leave a message on answering machine: (dejar mensaje en la contestadora)
___ Call my cell phone: (llamar a mi teléfono móvil)
___ Other (explain) (Otro(explique))__________________________________________
I authorize Dr. Rita Pediatrics, P.C. to share my child’s medical information with (please write his/her
name and relationship): [Autorizo a Dr. Rita Pediatrics, P.C. a discutir la información médica del niño/a
con las siguientes personas (favor escribir el nombre y la relación)]:
____________________________________________________________________________________
Medical treatment authorization without parent or guardian (Autorización a recibir
tratamiento en ausencia de padre o guardián)
I, ___________________, the parent/guardian of _____________________, confirm that the
people listed below have my permission, in my absence, to bring my child to Dr. Rita Pediatrics,
P.C. and I hereby authorize medical treatment.
_____________________ ______________________ ________________________
_____________________ ______________________ ________________________
Yo, ___________________, padre/guardián de ______________________, confirmo que las
personas nombradas debajo, tienen mi permiso para traer a mi hijo/a donde Dr. Rita Pediatrics,
P.C. y por este medio doy autorización para que reciba tratamiento.
_____________________ _______________________ ________________________
_____________________ _______________________ _______________________
____________________________________________
Signature (Firma)
________________________
Date (Fecha)