Document 56432

Juan Jose Ferreris, 1vtD. FAAP
Mar'.' Helen Perez, 1\'f.0 ::
Guide, M.D. FAAP
ChnstimMerritt, M.D. FAAP
Patient Legal Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _M/F: __ DOB: _ _ _ _ __ Mailing Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _City _ _ _ _ _ _ _ _ _TX 78_ __ Primary Care Physician: _____________
Primary Phone:
Pharmacy Phone:
Pharmacy Name & Address:
Parents/Guardians Information
Father's Name: - - - - - - - - - - - - - - - SSN# - - - - - - - DOB: - - - - - - - Father's Cell #: _ _ _ _ _ _ _ _ _ _ _Home #: _ _ _ _ _ _ _ _Other #: _ _ _ _ _ __
Mother's Name:
---------------- SSN# ----------- DOB: ---------
Mother's Cell #:
Home #:
Other #:
Guarantor Information
Guarantor Name: _ _ _ _ _ _ _ _ _ _TX DL#
Relationship to patient:
SSN#_ _-_ _-__ M/F: _
Phone: _ _ _ _ _ _ _ _ __
Billing Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ City
TX 78_ __
Insurance Policy Holder Information
Primary Insurance: ___________ 10#: ___________ Grp #: _ _ _ _ __
Policy Holder Name: _ _ _ _ _ _ _ _ _ _ _ _ SSN#: _ _ _ _ _ _ _ _ _ DOB: _ _ _ __
Relationship to Patient: _ _ _ _ _ _ _ _ _ _ _ _ _ Employer: _ _ _ _ _ _ _ _ _ _ __
Policy Holder Address (if different from Patients): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Secondary Insurance: ___________ 10#: ___________ Grp #: _ _ _ _ __
Policy Holder Name: _ _ _ _ _ _ _ _ _ _ _ _ SSN#: _ _ _ _ _ _ _ _ _ DOB: _ _ _ __
Relationship to Patient: _ _ _ _ _ _ _ _ _ _ _ _ _ Employer: _ _ _ _ _ _ _ _ _ _ __
Policy Holder Address (if different from Patients):
I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance of my account for any
professional services rendered. I have read all of the information on this form and have completed the above answers. I certify this
information is true and correct to the best of my knowledge. I will notify you of any changes in the above information. I understand and
agree that my signature below provides direct assignments of my insurance policy benefits to the doctor for payment of the total charges
for professional services rendered. I also authorize the release of any information pertinent to my case to any insurance company,
adjuster, attorney or other health care professional involved in my account/treatment. All patients must first stop at the reception desk
to satisfy any co-payments prior to seeing the physician.
Signature: _____________________ Today's Date: __________
AcknowleclgementF OFm
1 understand that as part of my healthcare, Children First Pediatrics originates and maintains health records describing
my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or
treatment. I understand that this information serves as:
• A basis for planning my care and treatment
• A means ojcommunication among the many health professionals who contribute to my care
• A source oJinJormation Jor applying my diagnosis and surgical information to my bill
• A means by which a third-party payer can verify that services billed were actually provided
• And a tool Jor routine health care operations such as assessing quality and reviewing the competence oj
health care proJessionals
I understand and have been provided with a Notice of Privacy Practices that provides a more complete description of
protected health information uses and disclosures. I understand that I have the right to review the Notice of Privacy
Practices prior to signing this acknowledgement. I understand that Children First Pediatrics reserves the right to change
its practices and to make the new provisions effective for all protected health information maintained by Children First
I understand that I have the right to request restrictions as to how my protected health information may be used or
disclosed to carry out treatment, payment, or healthcare operations and that Children First Pediatrics is not required to
agree to the restrictions requested. Children First Pediatrics will not use or disclose your health information without
your authorization, except as described in the Notice of Privacy Practices.
Children First Pediatrics records may contain information created by an entity other than Children First Pediatrics.
Children First Pediatrics is not responsible for the information contained therein (including the accuracy, completeness,
relevance, legibility or lack thereof of such incorporated records) .. Patient expressly requests release of all records
maintained by Children First Pediatrics concerning patient, including incorporated records. Patient acknowledges that
Children First Pediatrics has no and assumes no duty to patient regarding the content of or omissions from such
incorporated records.
Signature of Patient or Legal Representative
Date Signed by Patient or Legal Representative
Signature of Children First Pediatrics Witness
Date Signed by Children First Pediatrics
Children First Pediatrics was unable to obtain acknowledgement/consent because:
C Patient Sedated
n Patient Confused/Disoriented
C Patient Non-Responsive
Patient Refused - Reason _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
(Same date as the Notice of Privacy Practices)
Effective Date of the Notice of Privacy Practices
1.) Provide all insurance information so that we may bill your insurance
company, if you do not have your insurance card then we will expect
you to pay in full at the time services are rendered.
2.) We will give a 25% discount to patients without insurance when
payment is paid in full at the time services are rendered.
3.) Co-Payment is required at the time of service, there is a $25.00
returned check fee.
4.) It is the patients responsibility to verify benefits prior to receiving
5.) It is the patient's responsibility to verify that a doctor that you are
being referred to is a contracted physician on your insurance plan.
1.) We DO NOT accept walk-in appointments.
2.) Please call and cancel appointments ahead of time, if you are more
than 15 minutes late your appointment may need to be rescheduled.
3.) Due to the limited space for well child exams please try to schedule
them at least 2 months in advance.
4.) Inform receptionist of any insurance/address/phone number changes.
5.) Allow at least 2 business days for forms/prescriptions that need to
be filled out by physician and/or staff.
8627 Cinnamon Creek Bldg. 1 San Antonio, Texas 78240 641-KIDS
Payment/Eligibility Form
I, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ' hereby certify that I am eligible for
(name of insured)
_________________________________________________________ asof ______~---------------,through
(effective date)
________________________________ andIhavechosenDL ____________________________________________
(employer name)
(primary care physician of child)
to be my Primary Care Physician. I understand that if the above is not true or if I am not eligible under the terms of my
employer's Medical and Hospital Subscriber Agreement or if charges are incurred that are not covered by my insurance
plan, then I am liable for all charges for services rendered. Also, if the above is not true, I agree to pay in full for all
services received within 30 days of receiving a bill from my insurance company _______________________________
or the above named physician.
Signature of ParentiGuardian ___________________________________________ Date ___________________
Signature of Receptionist ________________________________________________ Date ___________________
8627 Cinnamon Creek Bldg. 1 San Antonio, Texas 78240 641-KIDS
Pediatric History
Child's Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Sex: 0 M
0 F
DOB: __________________________ BIRTH HISTORY Pregnancy Problems _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ o Alcohol
Maternal Use:
0 Cigarettes
o Recreation Drug
0 Medications
Birth Wt: _ _ _ _ _ _ _ _ _ _ _ Length: _ _ _ _ _ _ _ _ Gestation: _ _ _ _ _ _ _ _ _ _ _ _ __
Delivery: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Neonatal&reen: _____________________________________________________
Developmental Problems: ____________________________________________________
Safety Issues:
0 Car Seat
o Guns in Home
o ADD/ADHD/Leaming Problems
D Allergy Problems
o Smoke Alarms
o Day Care
o Secondary Smoke
o Flouride Supplement
o Father NMV\B;
o Mother~NI!...A!.LYYl!..:.!e.:....·_·_ _ _ _ _ _ _ _ _ _ _ _ __
o SiblingsN!.!:Mn:..J..!.!...~t,:.....:_ _ _ _ _ _ _ _ _ _ _ __
D Anemia/Blood Problems
D Birth Defects
D Cardiac Murmurs
D Diabetes Mellitus
D Hearing Problems
D Heart attacks/Stroke <so yrs
D High Blood Pressure
D High Cholesterol
D Lung Disease/TB
D Mental Illness
D Renal Problems
D Seizures
D Substance Abuse
o Step Family _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
(Practice Name) The attached notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please sign this cover sheet acknowledging receipt ofthe policy and return it to the receptionist. Review the policy carefully and let us know ifyou have any questions or requests. By my signature below, I acknowledge that I have received the Notice of Health Infonnation
Practices of
Children First Pediatrics
. I understand that the organization reserves
the right to change their notice and practices and prior to implementation will mail a copy of any
revised notice to the address I have provided. I understand that I have the right to request
restrictions as to how my health infonnation may be used or disclosed and that the organization
is not required to agree to the restrictions requested. I understand that I may revoke this consent
in writing, except to the extent that the organization has already taken action in reliance thereon.
Name of Patient
Signature of Patient
This notice describes how medical information about you may he used and disclosed and how you can get
access to this information. Please see the receptionist to request a copy.
Understanding Your Health
Each time you \i,it a Ill"pital. phY"l'lan or other
healthcare provider. a record or vour \ i,it is made,
Typically, this record contains vour symptoms,
examination and te,t re,ulls, d"'gllC"e" treatment
and a plan for future C~lrl' e'r treatment. This
infllnl1ation, often referred to as your health or
medical record, serves as a:
basis for planning your care and treatment
means of communication among the man v
health professionals who contribute to your
legal document describing the care you
means by which you or a Ihird-pany payer
can verify Ihal ,enlces billed II ere actually
tool in educal11lg health profc"",nal,
source of dala f"r medical research
source of inf(lnnation I()r public health
officials charged with imprl" Ing Ihe health of
thc nalion
source of data for facility planning and
tool with which we can assess and
conlinually work to improv'e the care liT
render and the outcomes we achieve
Understanding what is in your record and hlm your
health inf(lnllalion i, ",cd help, vou 10
ensure Its accural':
better undcC\land II ho, II hat. whl'n, where
and why othcr, may acc", vour health
make more intllnlled dec"ion, whcn
authorizing d"elosurc to other,
Your Health Information Rights
Although your health record is the physil'al
properlv of the healthcare practitioner or t'lcility
thai compiled it, the infllllllation belongs to you,
You have the right to:
request a restriction on certain uses and
disclosures of your infonnation as provided
by 45 UR IM.522
obtain a paper COPy "I Ihl' nolice of
infonnation practiccs upon rcque,t
in'pect and (lblain a copy of vour health
record as PH" ided I(If in 45 erR 11>4524
amend your hc~lilh rl'Cord as pru\'i,kd in 45
obtain an ~lc(uunting ur of your
health infonnation as pi'll\' idcd in 45 CFR
request C011lmunicailOns 01' your health
infllnnation bv altclllatl\c mcal" or al
altemative local lon,s
Wc rcserve the right to change our practICes and 10
make thc new pro\ isions effectiv'e for all protected
Should our
health intllrlllC1llon we Illallllaill.
intllfllllition practlccs change, Ill' will mail a
revised notice 10 Ihl' addre" you hay e supplied us,
To Report a Problem
If you have questions and would like additional
infiJnnatlOll, you may contact the Pri \ aev Officer
at thi, onlce,
S. (" 7, \ iola\cd, you can tile a complaint with thi, onlce
or 11lIh the secretary of Health and Human
Services, ('here will be no retaliation lilr liling a
Examples of Disclosures for Treatment, Payment and Health Operations Treatment:
Inl(lJInalion ublaincd by a nurse, physician or olhn lIlelllbn of vour healthcare team wi II bc reconkd III your record alld used 10
determine the l'Our,C of Irea[melll Illat should work
best Illr you, 'luur phYSician \\ ill documenl in
your record his or her expectations of Ihe mcmber,
oj' your healthcarc team,
Members of your
heallhcare team will thcn rccord the aclions they
In that lIay, [he
took and their observations,
physician will know how you arc responding 10
We will also provid~ sub,equent
heallhcare providers with copies of \'ariou, reporh
Ihal ,hould assist thcm in treating you,
Payment: :\ hill mav be ,,'nl lu vou or a third­
party payer, IhIS 1Il1'l1'1naliun Oil or accompanying
the bill may IIll'lulk inl"rl1lallon Ihalldcntifies you,
a~ well a:-. YUllr diagllosi~. pnK"l'durl's ano supplies
Health Opcrtltiom:
I, Risk \lanagement - ~ll'mber' ofth~ medical
staff or Ihe ri,k ur qllaln) IInpHl\Cment statT
may thl' IIlt'l1'1naIIOn 111 your health record to
assess the carc
dnd UlitCOllll~:-' III
your case and
uthers like' II rhis int(lrinallon will then be
used in an l'i't,"'1 10 C(lnllllUallv improve the
qualily and eITe,'tl\l'lll',,, 01 Ihe healthcare
and sen icc
mainlain the
II' you belie\ e your pri\·acy rights hav'e bccn
health infllrmalion ncepl 10 [he cxlent thai
action has already been lakc'n
This organization is required to: 3, Wc will nol usc or d"l'lo,c your health infonnation
without your \\rl[ll'n aulhorJ/alioll, except as
described in [his 110[1((
rC\"{Jkc your autilori/ation ttl 11~(' or disclose
Our Responsibilities pro\idc you 11lIh a 1l0tll'C as to our legal
duties and privacy pracllces lIith respect to
infllnnatlon Ill' collect and maintain about
abide bv Ihl' [l'llllS ol'this notlcc
notify YULl if \\c arc ullable to agree to a
rcquesll'd rl'slriclion
acco1l1modate reasonable requests you may
ha\c to eomlllunicate health inillflnation by
allcmative means or at altemativc locatIOns
notit~ you of a breach of ·'unsecured"
protected health infllflnation
pnl\ Idc.
Business ,\ssociates - I here arc some
,en ices provided in our organization Ihrough
cuntacts with business associate, I sample,
include radiology, laboratory, copy ,crvices,
tralhcription services, billingserv Ices, ctc,
Whcn these scn'ices arc contracled, we mav
di,close your health information lu uur
buslllt:ss associate so that they can perillflll
X, thc job we hay e askc'd [hcm to do and bill you
or vour Ihird-pariV payer fllf services
rendered, To prolecl V(lur health infonnation,
however, \I e requ irl' Ihe busincss associate to
apprupria\clv satcguard ](Iur infllflllation,
I\otifkation - We may use or disclose
int\l11nalion 10 nolil~' or assist in notifying a
family member, personal representali\ c, or
another person responsible Illr your care, of
your location and general condition,
Communication With Family - Health
profcssionals, using their be,1 judgment, may
disclose to a family member. other relati\e,
close personal friend or any olher person you
identify, health infonnation relevant to that
person's in\ul\ellleni 111 vour care or payment
relaled 10 your care,
Research - Wc mav d"close infollnation to
IT,earcher, whcn Iheir research has been
:lppro\ed bv an institutiunal review board that
has rc\ Icwed the research proposal and
eSlablished proloc(lls I" cnsure the privacy of
v uur health int(lnn~III(lll.
Funeral Directors - We may disclo,e hcalth
infllflnation to funeral directurs consistent
with applicable law to carry out their duties,
Organ Procurement Organizations
Consistent with applicable law, \1 e may
disclose health info11l1ation to organ
procurement organizations or other enlities
engaged in the procurement. banking or
Iransplantation or organs tllf the purpose of
li"ue donal ion and Iransplant.
\\arketing - We may contact you 10 provide
appoinlllll'ni rcmindl'r, ur infonllation about
treatmenl alle111all\ es or uther health-related
bl'llctits and sen icc's Ihal may be of interest
Food and Drug Administration (FDA) ­
We may disclose to the FDA health
infllnnation relative to ad\crse cvents \lith
respect to fllod, supplemcnls, product and
I() Workers' Compensation - Wc may disclose
health infl>nnation to the e~tenl authorized by
and to the extent nccessary 10 c011lply wilh
laws relating to workers' compensation or
olher ,,,nilar l'rugr:l11lS established by law,
I I, ruhlit' lIealth \s required by law, we may
disclose your health int(lnllation to public
hl'alth or legal aUlhorilies charged wilh
pr('\ cnting ur contrulling disease. injury or
I~, Law Enforcement - We may disclose health
infllnnatioll lelr lall cnllm:ement purposes as
required bv la\\ (Ir in rcsponse to a valid
Fedcr:li la \1 makes prov"ion tllr your health
infl>nllallllll 10 be rclea,cd 10 an appropriale health
oversighl agencv, public health authority or
attomey, pro\ ided [hal a \Iork tl)fCe 11lc11lber or
business :hsociale b,'li,'\ c, In good faith lhat we
have engaged in unlawful conduct or have
olherwise violated protessional or clinical
standards and are potentially endangering one or
more paticnts, workers or the public,
This notice is effective as of 11112010 and
will remain in effect ulIlil revised,