Child New Patient Form Step 1 of 11 9% Patient Last Name* MI Patient First Name* Race* American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Hispanic, Latino or Spanish Yes Gender* Male Female Date of Birth* MM slash DD slash YYYY Social Security Number* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Primary Phone* Cell Phone Home Phone Phone Number* Secondary Phone Cell Phone Home Phone Secondary Number Email Address* Responsible Parent Information if Patient is Under Age of 18 Mother's InformationLast Name* First Name* Middle Name Mom's Date of Birth* MM slash DD slash YYYY Occupation Father's InformationLast Name* First Name* Middle Name Dad's Date of Birth* MM slash DD slash YYYY Occupation Preferred Pharmacy Pharmacy Phone Pharmacy Fax Referred by Who referred the patient to us?Insurance Name Policy # Subscriber/Policy Holder's Name Subscriber DOB The policy is under: Patient Spouse Parent Select the relationship of the policy holder.Secondary Insurance Policy # Emergency Contact Phone # Relationship to Patient The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understandthat I am responsible for any copays and/or balance. I also authorize Family Health Care Center or insurance company to release any information required to process my claims.Patient/Guardian Signature* Relationship to Patient* TO BE FILLED OUT BY PARENT OR GUARDIANDoes the child attend Day Care or After School Care? (please circle) Yes No Name of Day Care Phone Number of Day CarePREGNANCY AND BIRTHMother's age at birth* Did mother have any illness during pregnancy?* Yes No Did she take any medicines except vitamins/iron?* Yes No Was the baby on time?* Yes No Baby's birth weight*Baby's Length (inches)*Did he/she have any trouble starting to breathe?* Yes No What type of delivery?* C-Section Vaginal Forceps Vacuum Any other problems in the hospital (jaundice, etc)?* Yes No If yes, what kind?* PAST MEDICAL HISTORY Where has you child gone for check-ups until now?* Any allergies to medicines, foods, insects?* Yes No Date of last dental check-up?* MM slash DD slash YYYY Date of last check-up?* MM slash DD slash YYYY Any hospitalizations?* Yes No Reason for hospitalizations Any Surgeries?* Yes No If yes, for what? Any serious injuries (head, broken bones, wrecks?)* Yes No If yes, for what? Any medications taken regularly?* Yes No If so, which ones? Separate each with a comma (,)Do you have record of immunizations?* Yes No FEEDING AND NUTRITIONIs his/her appetite usually good?* Yes No Was there severe colic or unusual feeding in the first 3 months?* Yes No Do any foods disagree with him/her?* Yes No Does he/she take vitamins?* Yes No Does he/she take fluoride?* Yes No For the first six months, was he/she breast/bottle fed?* Breast Bottle If still on formula, which one? FAMILY HISTORYAre the child’s parents in good health?* Yes No Circle any diseases this child’s family has had: (include parents, brothers/sisters, grandparents, aunts/uncles, and cousins) anemia, asthma, allergies, diabetes, TB, AIDS, high blood pressure, heart trouble, mental illness, drug or alcohol problems, inherited illness, cancer, List age, gender and general health of brothers and sisters belowHave any children died?* Yes No REVIEW OF SYSTEMS1. Has your child had frequent ear infections?* Yes No 2. Any Eye Problems?* Yes No 3. Any problems with teeth?* Yes No 4. Does he/she have frequent colds?* Yes No 5. Is there asthma, pneumonia, or recurrent cough?* Yes No 6. Is there a heart murmur or heart problems?* Yes No 7. Any problems with urination?* Yes No 8. Ever had a UTI or Urinary Tract Infection?* Yes No 9. Any constipation or diarrhea?* Yes No 10. Any convulsions or nervous system problems?* Yes No 11. Any eczema, hives, or other skin condition?* Yes No 12. Any anemia?* Yes No Please list any other physical complaints: DEVELOPMENT AND BEHAVIORAt what age did your child roll over? (Months) At what age did your child sit alone? Did he/she say any word by age one year? Yes No Does the child seem advanced or behind others his/her age? Yes No If yes, in what way? Does he/she have trouble sleeping?* Yes No What grade is he/she in? Any trouble in school (behavioral or academic)?* Yes No Check if the patient has any of the following.* Nail Biting Thumb Sucking Bed Wetting Problems with Toileting Bad Temper Hyperactivity Nightmares Speech Problems SAFETY ENVIRONMENTDo you live in a: House Apartment Mobile home Other Any pets in the home? Yes No Do you know the hottest temperature of the water heater? Yes No Is there a working smoke alarm on each floor?* Yes No Does he/she always use a car seat/seat belt in the care?* Yes No Are there any smokers in the family?* Yes No Are there any problems in the condition of your home? Yes No (peeling paint, insects, mice, no heat/air, etc)If yes, please explain Does he/she always wear a helmet when biking?* Yes No Do you have well water or city water?* Well Water City Water Please explain any significant problems below: Minor Patient Care PolicyThank you for choosing Family Health Care Center to provide healthcare to your minor. In order to remain compliant with HIPAA rules and regulations, Family Health Care Center has adopted the following policy regarding treatment of a minor: All minor patients must be accompanied by a legal guardian/caretaker when coming to the office for treatment, unless the patient is coming in for reproductive health, or the office staff has received written authorization to treat the patient in the form of the Consent for Minor Patient to be Treated document. Any lab results/procedures regarding reproductive health of a minor are protected by law and may not be disclosed without express consent of the minor patient. Therefore, lab results will not be disclosed over the phone to anyone but the patient, unless consent to r elease the results have been documented in the patient’s chart by the treating provider. If consent has not been given to release results over the phone, then an office visit with the minor patient and guardian mus t be scheduled to discuss results with the treating provider. For the health of the patient, treatment for any reproductive diseases/conditions that may have been uncovered during testing/procedures may begin prior to the office visit to discuss results with legal guardian/caretaker. Family Health Care Center requires that a minor patient be seen and accompanied by a parent or legal adult guardian at the initial visit. If the parent or guardian would like the minor patient to be seen unaccompanied for any subsequent visits we must have signature authorization. Please fill out the form in its entirety and fax, mail, or deliver to the office. Person giving consent for treatment:Name* First Last Daytime Phone*Relation (check one): Parent Legal Guardian Caretaker Authorization I give consent to have "My Child" seen and treated by Family Health Care Center without my presence. I give Family Health Care Center the right to discuss and treat the above patient's disease, not limited to any prescriptions and procedures deemed necessary by providers at Family Health Care Center. I give consent for treatment to begin on the date listed below and understand that I may revoke this consent by giving Family Health Care Center written notice.By selecting the checkbox labeled yes you agree to the above authorization.* Yes By selecting the checkbox labeled yes you agree to the above authorization.Parent/Guardian Signature* FHCC Insurance Disclaimer Please be aware that you as the patient are responsible for any charges that are not covered by your insurance. It is the patient’s responsibility to make sure that our office is in network and is participating with your insurance plan . It is also the patient’s responsibility to know if the insurance requires you to have a designated Primary Care Provider (PCP). If you are not sure if our office is participating with your plan or if your insurance requires you to have a dedicated PCP, please call the customer service number conveniently located on the back of the insurance card to verify participation make any necessary changes. With insurance constantly changing and the implementation of the AFFORDABLE Care Act (Obamacare), Our office can NOT accommodate the phone calls required to make sure we are in network with every patient’s insurance plan and/or call to verify if they will deny your medical claim due to missed premium payments. We will file your insurance; this does not mean in any way that our office is a participating provider for your health plan, or that your insurance will pay for your visit. Therefore, you may receive an additional bill for any balances that we re unpaid by your insurance. Please note that if your insurance premiums are not paid, any medical claims during that period will be denied or possibly pend. For patients with PCPs different than the providers in our office - it is the patient’s responsibility to change their PCP to the appropriate provider or to provide written documentation that a PCP is not required for the patient’s specific plan. If you are currently in a grace period at the time of your visit, you will be treated as a SELF - PAY patient. For patients that have managed health care plans - You MUST provide proof of FULL premium payment at the time of visit. If payments are not made by the end of your premium grace period, you will be held responsible for any and all charges for t reatment from your visit. Therefore, any patient that is currently in a grace period will be treated as a SELF PAY patient.Parent/Guardian Signature* PLEASE REMEMBER Photo ID Insurance Card Copays All Medications Currently Prescribed Patient Insurances Preferred Services Many insurance companies are now specifying which commercial laboratories, hospitals, radiology services and other services you may use for studies. It is YOUR responsibility as the patient to be a ware of this information. For instance, if your lab work is sent to a non - preferred lab you will be responsible for payment. Our in - office lab can perform only limited testing and when appropriate, we will perform what we can in - house. All other specimens m ust be sent to a reference lab such as labcorp. Please indicate your insurance carrier’s preferred lab and/or radiology services. Inaccurate or erroneous information will re sults in you being held responsible for all lab charges. If you are unsure, please contact yo ur insurance carrier by calling the customer service number listed on the back of your insurance card.Laboratory Lab Corp Quest Diagnostics Radiology Services: East Georgia Regional Medical Center Parent/Guardian Signature* Patient Acknowledgement Review or Receipt of Notice I understand FHCC has a legal responsibility to protect patient privacy. To do this, the practice strives to keep patient inf ormation confidential and to safeguard the privacy of all patient information. I understand the FHCC has the authority to use and disclose my private health information to carry out treatment, payment, an d healthcare operations, and that my private health information will not be released to ot her activities unless I sign a release authorizing this disclosure. By signing this form, I acknowledge that I have been provided with FHCC’s Notice of Privacy Practices to review, and have bee n informed that I may obtain a copy upon request. I understan d that Family Health Care Center has the right to change its Notice of Privacy Practices. If so, FHCC will issue a revised Acknowledgement of Review/Receipt of Privacy Practices. Parent/Guardian Signature* HIPAA FORM Please list any family member or other persons / physicians to whom Family Health Care Center may release information concerning your medical records:Name PhoneRelationship Name PhoneRelationship Name PhoneRelationship Please Note: Our automated computer system will automatically call all patients with appointments 2 days prior to t he scheduled appointment date. Please confirm YES with the system by pressing #1 or can cel the appointment by pressing #2. Please list the best number for all appointment reminder callsPlease list the best number for all Appointment Reminder CallsMay Family Health Care Center leave messages on your home answering machine or voicemail? Yes No Please indicate if you would like to create a patient portal account. With this account, you will be able to review your lab results, ask non - urgent medical questions, request medication, and schedule appointments. Yes No Parent/Legal Guardian Signature* Administrative Policy Family Health Care Center (FHCC) is striving to do everything possible to hold down the cost of medical care to all by ensuring proper payment to our office. You, the patient, can help us by adhering to the following administrative policy. By signing at the bottom of the Administrative Policy , you are indicating that you understand our policies and agree to adhere to them. If you have questions prior to signing , please ask at the front desk. Appointments It is a patient’s responsibility to provide FHCC with complete and correct information. You must bring your current insurance cards to each visit. If you fail to do so and your new insurance requires a preauthorization or we find that our services will not be reimbursed, or we are unable to properly bill y our insurance, any balances will become the patient’s responsibility. It is the new patient’s responsibility to complete all patient and medical history forms at the time of their visit. All appointments must be cancelled at least 24 hours in advance . If you fail to cancel the appointment and do not show up, a $25 No Show fee will be assessed to your account. If you continue to neglect to show up for appointments, we may have no other option except to dismiss you from our practice. Please understand that this patient practice is costly to our office. All patients are required to provide their Social Security Number upon their initial visit. Under no circumstances will a patient be allowed to be seen without providing it. FHCC respects your privacy and will not share your personal information with anyone other than your insurance carrier, Collection Agency, or whomever you have ag reed in writing to allow access to your account or health information. Insurance FHCC will bill all participating insurance carriers as a courtesy to our patients. If your insurance fails to pay your claim within 60 days from the date it is billed, the balance will become the patient’s responsibility . Assignment of Benefits: By signing this policy the patient or guarantor authorizes payment of medical benefits to FHCC for all in - network insurance carriers. Appeals: By signing this policy, the patient or guarantor agrees to allow FHCC to submit and follow up on medical appeals on behalf of the patient. Cooperation: The patient or guarantor agrees to cooperate with the insurance company and with FHCC to provide any information necessary to properly process the medical claim. Payments All copays, co-insurances, and deductibles are due at the time of service. All payments may be made via cash, check, or credit card (Visa, MasterCard, Discover, American Express, Debit Card). Any payment made by check will be processed electronically and w ill be automatically debited from your account within 24 hours. Credit Card Payments: Your signature at the bottom of this policy will stand as a signature on file for any payment you authorize by credit card via the telephone, fax or Internet. Returned checks: All accounts will be assessed a $40 processing fee for returned checks. If you fail to reimburse FHCC within 10 days of notification from your bank, you will not be allowed to use a check for any future payments. Out of Network Patients: If FHCC i s not a participant in your insurance network, you will be required to pay the portion of your balance not paid by your insurance company. Uninsured Patients: You will be considered a Self Pay Patient (see paragraph vi below). Self Pay Patients: You must bring a minimum of $150 to each visit. This does not mean your visit will be less than $150. It will depend on the type of visit and /or any tests or procedures that may be provided. If you pay your balance at the time of service we will provide a 30% discount at Check Out. If you have insurance of which we do not participate with, our staff will provide you with an encounter receipt which will include all information necessary for you to be reimbursed by your insurance carrier. All balances to FHCC will be due at the time of service. Collections Patient Balances: Balances including copays, co - insurances, and deductibles that are not paid in full at the time of service creates costs to FHCC. Balances are due at your office visit. If you have a balance after your insurance has paid, you will receive a statement to be paid within 2 weeks of receipt. If after 2 statements have been sent and FHCC has not received your payment due at 60 days, we may attempt a courtesy phone call requesting that you return our call. If no payment is received, at 90 days your balance will be turned over to a collection agency. FHCC will add a 30% collection fee to your total balance to cover collection costs incurred by FHCC. Hospital Admissions Dr. Riley believes that you are entitled to make informed decisions regarding your medical care. To assist you in making an informed decision, Dr. Riley hereby notifies you that he has an ownership interest in East Georgia Regional Medical Center, which is a physician - owned hospital, pursuant to 42 C.F.R § 4.89.3. Please address any questions to the front office staff or to our billing/insurance staff at (912) 489 - 4090, ext 127, 128 or 129. Anyone who fails to comply with any part of our policy may be asked to reschedule so you will have time to comply with the policy. Those who repeatedly miss appointments, are noncompliant with a plan of care, or are abusive to our staff may be rescheduled or dismissed from our practice. If you have any additional questions or concerns you may contact the Practice Administrator at (912) 489 - 4090, ext 123. This policy remains in effect until superseded. You will be provided a copy of this policy upon request. Parent/Legal Guardian Signature* Dear Patient, Thank you for choosing us to provide healthcare for you and your family. We at Family Health Care Center constantly strive to provide you with the ultimate patient experience and customer service. We are excited to offer an online patient portal for o ur pa tients so that you can have faster, reliable communication that is accessible to you at all times. Our internet - based patient portal, Next MD, simplifies communication with your physician or provider and eliminated time - consuming phone calls to the practi ce. Whether you want to schedule an appointment or review your test results , the patient portal delivers the information you need through a convenient, easy - to - use patient portal. NextMD is a secure, confidential, and easy - to - use website that gives patien ts 24 - hour access to their medical information. It uses the latest encryption technology to deliver secure communication between patient and our office. By signing up and enrolling in N extMD, you will be able to: Correspond online with Family Health Care C enter, that is channeled to proper personnel for quicker response times Request appointments and receive appointment reminders Access important health information from your medical record including: medications, immunizations, and test results View medicat ion lists and request prescription refills directly through your provider/provider nurse Obtain educational information Maintain account information including username, password, access privileges, and email address How do you sign up?? Patients and their legal guardians can sign up for NextMD. All you have to do is provide your name and e mail address to us below. We will the n provide you with and instruction sheet with a temporary password or enrollment token. The en rollment token will allow you to log in to the system and create your own private username and password. After you sign up and begin u sing the patient portal, Next MD will generate a notice that will be emailed to your personal email account to notify you that you have important information waiting in you NextMD account. We look forward to providing this service to you and hope that you will take advantage of its many benefits.I have an email and would like to sign up for NextMD , your online patient portal. Yes No, I do not have an email address Not interested Email Date of Birth MM slash DD slash YYYY AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION (THIS FORM MUST BE COMPLETED IN FULL TO RECEIVE RECORDS.) I authorize the use and/or release of my protected health information as described below. I understand that the information u sed or released as a result of this Authorization may no longer be protected by federal privacy laws and may be further used or released by persons or organizations receiving it without obtaining my authorization. I may refuse to sign this Authorization, which will not aff ect my ability to o btain treatment or payment of claims. I have the right to revoke this authorization by providing written notice to Family Hea lth Care Center. Revocation of this Authorization will not affect any action taken before receipt of the written revocation. I AUTHORIZE: Name of Physician / Health Care Facility / OtherAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code TO RELEASE PROTECTED HEALTH INFORMATION TO: Name of Physician / Health Care Facility / OtherAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code HEALTH INFORMATION TO BE RELEASED: All Medical Records Immunization Records Lab Reports X-Ray Reports Billing Reports Other Describe Other OR THE FOLLOWING DATE(S) OR TIME FRAMEFrom MM slash DD slash YYYY To MM slash DD slash YYYY Federal and state laws require special per mission to release certain information. Please check if these records SHOULD BE released Mental Health Alcohol and/or Drug Abuse HIV/AIDS test results Development Disabilities PURPOSE OR NEED FOR DISCLOSURE: (Check Applicable Categories) Further Medical Care Patient's Request Insurance/Eligibility Benefits Disability Determination Legal Investigation Other Describe Other EXPIRATION: MM slash DD slash YYYY Set the date this authorization will expire. If I do not indicate a date, this will expire one (1) year from the date on my signature below. A photocopy of this authorization is as valid as the original.SIGNATURE: I understand that this author ization is voluntary. I am confirming my authorization that the health care provider may use and/or disclose to persons and/or organizations named in this form the protected health information described in this form.SIGNATURE* Date* MM slash DD slash YYYY If this authorization is signed by a representative on behalf of the patient, complete the following:Representative's Name: Relationship to patient:
