healthy kids r us · 2020-07-08 · healthy kids r us patient information healthy kids r us, p.c....

Healthy Kids R Us Patient Information

Healthy Kids R Us, P.C. 11 Dunwoody Park, Suite 190 Dunwoody, GA 30338

Phone: 770-558-3150 Fax: 770-558-3511

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LAST NAME FIRST NAME MIDDLE NAME CALLED

STREET ADDRESS APPT # CITY STATE ZIP MARITAL STATUS

AREA CODE HOME PHONE AREA CODE CELL PHONE SOCIAL SECURITY # SEX DATE OF BIRTH AGE

EMPLOYED BY SPOUSE'S NAME EMPLOYED BY

EMPLOYERS ADDRESS EMPLOYERS ADDRESS

OCCUPATION BUS. PHONE & EX OCCUPATION BUS. PHONE & EX

NEAREST FRIEND OR RELATIVE

NOT LIVING WITH YOU

RELATIONSHIP TO INSURED (ALIAS) PHONE

POLICY HOLDER/INSURANCE INFORMATION COPIES OF INSURANCE CARD REQUIRED

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LAST NAME FIRST NAME MIDDLE RELATIONSHIP TO PATIENT

STREET ADDRESS APPT # CITY STATE ZIP

DATE OF BIRTH SOCIAL SECURITY # HOME PHONE

EMPLOYED BY BUS. PHONE

Insurance Co. Name

Mailing Address City, State, Zip

(A/C) Phone # ( ) - ( ) -

Policy/Contract #

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LAST NAME FIRST NAME MIDDLE RELATIONSHIP TO INSURED (ALIAS)

STREET ADDRESS APPT # CITY STATE ZIP

DATE OF BIRTH SOCIAL SECURITY # HOME PHONE

EMPLOYED BY BUS. PHONE

Insurance Co. Name

Mailing Address City, State, Zip

(A/C) Phone # ( ) - ( ) -

Policy/Contract #

REFERRING INFORMATION

REFERRAL SOURCE

RECEIPT OF NOTICE OF PRIVACY PRACTICES (Turn Over)

This is to acknowledge that I have received a copy of Hea l t hy K ids R Us Notice of Privacy Practices.

Date:

Signature: Relationship to Patient:

Healthy Kids R Us Patient Information


Phone: 770-558-3150 Fax: 770-558-3511

I REQUEST THAT PAYMENT OF AUTHORIZED benefits be made to Healthy Kids R Us. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable to related services.

Date Signature

I hereby authorize the release of any medical information, including information related to psychiatric care, drug and alcohol

abuse and HIV/AIDS confidential information, necessary to process insurance claims or any medical information that is required

for any health care related utilization review or quality assurance activities or any healthcare professional requiring this

information.

I hereby assign and authorize payment to Healthy Kids R Us of all medical and/or surgical benefits, including major medical

policies, to which I am entitled to under any insurance policy or policies, under any self-insurance program, or under any benefit

plan.

I understand and acknowledge that this assignment of benefits does not relieve me of my financial responsibility for all medical

fees and charges incurred by me or anyone on my behalf and I hereby accept such responsibility, including, but not limited to,

payment of those fees and charges not directly reimbursed to [Practice Name] by any insurance policy, self-insurance program

or other benefit plan.

This authorization shall remain in effect until revoked by me in writing. A photocopy of this authorization shall be considered

as effective and valid as the original. I understand that I have the right to receive a copy of this authorization.

PERSON PROVIDING THE AUTHORIZATION ________________________________________________________________

RELATIONSHIP TO PATIENT IF NOT PATIENT

Date

ALTERNATIVE CONTACT AUTHORIZATION

I DO DO NOT authorize you to contact or leave messages at my place of work.

Date: Signature:

I DO DO NOT authorize you to contact me at my e-mail address.

(e-mail address if authorized )

Date: Signature:

I hereby authorize you to leave messages on my home answering machine regarding

appointments and to inform me that laboratory results are available. The laboratory results

are NEVER left on the answering machine. You have to call the office to get them.

Date: Signature:


Phone: 770-558-3150 Fax: 770-558-3511

PATIENT HISTORY

Reviewed By: Date:

NAME Male Female

First Middle Last Race

Name child is called by

Where was the child born?_

Birthdate_

Obstetrician

Is child adopted?_

At what age?

Is child aware?

Full term pregnancy?

Premature?

Type of delivery? _

Mother: Have you had breast surgery?

Did you take hormones or medicines during pregnancy? _

Problems at birth or in first few weeks?_

Birth wt.

Length

Head Circ.

Apgar

Is your child taking medication now?_

FAMILY HISTORY Please let us know if there is a family history for any of these medical conditions. Please consider all family members related to the child including

siblings, parents, aunts, uncles, grandparents, and cousins. Circle YES or NO to confirm each a positive or negative response to each question.

YES or NO YES or NO YES or NO YES or NO YES or NO YES or NO YES or NO YES or NO YES or NO

Allergies Asthma/Wheezing Birth Defects Bleeding Tendencies Diabetes Early Heart Attacks Emotional Problems Epilepsy High Blood Pressure

YES or NO YES or NO YES or NO YES or NO YES or NO YES or NO YES or NO YES or NO YES or NO

High Cholesterol Hip Disorders in Infancy Kidney Disease Mental Problems Thyroid Disease Tuberculosis Lazy Eye Other Heart Disease Other Illnesses

SOCIAL HISTORY

BIRTH DATE HT. WT. EDUCATION LEVEL

MOTHER

FATHER


Phone: 770-558-3150 Fax: 770-558-3511

SOCIAL HISTORY (CONTINUED)

Has there been a separation, divorce, or death?

When?_

Who is legal guardian?

With whom does child live?

Has there been a remarriage?

What has been the attitude of your child to the situation? _

1. Do you and your family have a religious preference? YES NO If yes, please list: _______________________________

2. Parent’s Marital Status: SINGLE MARRIED DIVORCED WIDOW

3. Has child’s behavior changed due to recent changes in family status? If so, specify: _________________________________

4. Do you have a gun at home? YES NO

5. Are there pets at home? YES NO If so, specify: ____________________________

6. Does anyone at home smoke? YES NO

7. Is the family experiencing any financial hardships? YES NO

8. Do the parents mostly agree or disagree with how to raise the children? AGREE DISAGREE

9. List all family members living in the same home as the child or children:

__________________________________________________________

_______________________________________________________________________________________________ This form completed by Date Relation to patient

11 Dunwoody Park, Suite 190 Dunwoody, GA 30338

Phone: 770-558-3150 Fax: 770-558-3511

CONSENT TO TREAT FORM

I hereby give authorization to the following named individuals to accompany my child/children for treatment at Healthy Kids R Us: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ This includes, but is not limited to, medical evaluation, treatment and administering of immunizations. _________________________________________________ ________________________ (Parent Signature) (Date) ___________________________________________________________________________ Child’s Name Date of Birth ___________________________________________________________________________ Child’s Name Date of Birth ___________________________________________________________________________ Child’s Name Date of Birth ___________________________________________________________________________ Child’s Name Date of Birth ___________________________________________________________________________ Child’s Name Date of Birth


Phone: 770-558-3150 Fax: 770-558-3511

How did you hear about us? Please take a moment to let us know how your learned about our practice. Please check or select each of the sources that you reviewed prior to visiting our office.

Internet

Website Google Search Engine Google Maps / My Business Places Addresses Google Ad

Social Media (Facebook/Instagram)

Facebook Instagram Other ________________________________________

Referring Doctor

o ______________________________________________

Family / Friend / Existing patient (Word-of-Mouth)

o __________________________________________

Local Newspaper, Magazines, other Print Advertisements

o _____________________________________________

Physician Review Websites

o ___________________________

Insurance Directory

Telephone Book/Yellow pages

Community Event

o _____________________________________________

Other _____________________________________________


Phone: 770-558-3150 Fax: 770-558-3511

HEALTHY KIDS R US

PRACTICE FINANCIAL POLICY If you have medical insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our financial policy.

• Co-payments for office services are required at the time you register.

• As a courtesy, we will process and file your insurance claims for services at no cost to you.

• For services that are covered by insurance, the practice requires payment of approximately 20% of the total estimated charges or the co-payment specified by your insurance.

• For services that are not covered by insurance, the practice requires payment of 100% of total charges unless payment arrangements have been worked out.

• Returned checks are subject to a handling fee of $20.00. In the event your account must be turned over for collection, you will be billed and are responsible for all fees involved in that process.

You must realize that: 1. Your insurance is a contract between you and your employer and/or the insurance company.

While we may be a provider of services, we are not a party to that contract. We encourage you to contact your insurance carrier personally in order to remain informed of your benefits.

2. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily

select certain services they will not cover or which they may consider medically unnecessary, and, in some instances, you will be responsible for these amounts. We will make every effort to ascertain your coverage for our services before treatment and will make you aware of our findings. However, this does not guarantee payment from your insurance carrier.

We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. If you have any questions about the above information, or any uncertainty regarding your insurance coverage, PLEASE do not hesitate to ask us. We are here to help you. PLEASE READ THE ABOVE CAREFULLY BEFORE SIGNING Signature: Date: (Patient and/or Responsible Party)


Phone: 770-558-3150 Fax: 770-558-3511

Additional Policies

Insurance / Provider Change Policy Most insurance plans, specifically HMO and POS, require policy holders/insured members/patients to call your insurance carrier prior to your appointment in order to change your primary care provider (PCP). Failure to contact your insurance company prior to your appointment will result in you being responsible for full payment for services rendered versus having your insurance company cover the charges. Therefore, we strongly urge you to contact your insurance company in advance to notify them of your decision to change providers. Smart Phones / Cell Phones / Audio & Video Recording Policy Our office respectfully requests that you do not use your smartphone/cell phone/electronic devices in our office during child's appointment. This is for the safety and privacy considerations of all our parents and patients. If for some reason you need to accept a phone call, we ask that you step outside the office to continue your conversation in private and minimize disruption. Also, due to HIPAA privacy laws and concerns, audio or video recording are not allowed for any reason. Disruption Policy Our practice has a zero-tolerance policy against aggressive behavior, unreasonable expectations, bullying, profanity, lying, and verbal abuse towards our staff from our patients and their family members. Any display of this behavior will be subject to being terminated as a patient from this office.


Phone: 770-558-3150 Fax: 770-558-3511

Receipt of Notice of Privacy Practices

I, ____________________________________, have been made aware that a copy of the HIPAA is

located in the waiting areas of Healthy Kids R Us, P.C. and am aware that I can request a printed copy.

Signature: _____________________________________________________ Date: ______________

Relationship to Patient: _____________________________________________

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will say “yes” to all reasonable requests.

Your Rights

Notice of Privacy Practices • Page 1

Your Information.Your Rights.Our Responsibilities.This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

continued on next page

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations.

• We are not required to agree to your request, and we may say “no” if it would affect your care.

• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.

• We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on page 1.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.


Your Rights continued

www.hhs.gov/ocr/privacy/hipaa/complaints/

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care

• Share information in a disaster relief situation

• Include your information in a hospital directory

• Contact you for fundraising efforts

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

In the case of fundraising: • We may contact you for fundraising efforts, but you can tell us not to contact you again.


How do we typically use or share your health information? We typically use or share your health information in the following ways.

Treat you • We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

• We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services

• We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

Our Uses and Disclosures

continued on next page


How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

• We can share health information about you for certain situations such as: • Preventing disease• Helping with product recalls• Reporting adverse reactions to medications• Reporting suspected abuse, neglect, or domestic violence• Preventing or reducing a serious threat to anyone’s health or safety

Do research • We can use or share your information for health research.

Comply with the law • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

• We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

• We can use or share health information about you:• For workers’ compensation claims• For law enforcement purposes or with a law enforcement official• With health oversight agencies for activities authorized by law• For special government functions such as military, national security,

and presidential protective services

Respond to lawsuits and legal actions

• We can share health information about you in response to a court or administrative order, or in response to a subpoena.

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html


• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of This NoticeWe can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Our Responsibilities

This Notice of Privacy Practices applies to the following organizations.

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

healthy kids r us · 2020-07-08 · healthy kids r us patient information healthy kids r us, p.c....

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