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New Patient Form

"*" indicates required fields

New Patient Form

Please fill out all of the fields. All answers will be kept confidential. If you have any questions, please ask us, and we'll be happy to assist you.

Who Referred You to Us?*

Patient Information

Guardian Type*

Father

Guardian

Father's Name*

First Name Middle Last Name

Father's Date of Birth*

MM slash DD slash YYYY

Guardian Type*

Mother

Guardian

Mother's Name*

First Middle Last

Mother's Date of Birth*

MM slash DD slash YYYY

Home Phone*

Father/Guardian's Phone

Mother/Guardian's Phone

Email*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Physical Address*

Street Address Address Line 2 City State ZIP Code

What language do you speak at home?*

Marital Status*

Married

Single

Divorced

Father's Ethnicity/Race*

Asian

American Indian

Black/African American

Caucasian

Hispanic

Hawaiian

Latino

Other

Mother's Ethnicity/Race*

Asian

American Indian

Black/African American

Caucasian

Hispanic

Hawaiian

Latino

Other

Father's Employer Name*

Father's Employer Phone*

Mother's Employer Name*

Mother's Employer Phone*

Please list one person that does not live with you that we can contact in case of emergency. Please list phone number including area code.

Name

Phone

Patient's Name*

First Middle Last

Patient – Date of Birth*

MM slash DD slash YYYY

Patient – Gender*

Male

Female

Patient – Ethnicity/Race*

Asian

American Indian

Black/African American

Caucasian

Hispanic

Hawaiian

Latino

Other

*Ethnicity: (A) Asian, (AI) American Indian, (B) Black/African American, (C) Caucasian, (H) Hispanic, (HW) Hawaiian, (L) Latin, or (O) Other* (Please choose the race or ethnicity you most closely associate yourself with and choose only ONE for the purpose of this form.)

Insurance Information

Insurance Status

I have insurance

I do not have insurance

Copay not required

Primary Insurance Company*

Insurance Claims Address

Street Address City State ZIP Code

Subscriber Name*

Subscriber – Date of Birth

MM slash DD slash YYYY

Insurance Effective Date

MM slash DD slash YYYY

Subscriber Insurance ID

Subscriber Group Number

Secondary Insurance

I have Secondary Insurance

I do not have Secondary Insurance

Secondary Insurance Company Name

Insurance Address

Street Address City State ZIP Code

Subscriber Name

Subscriber – Date of Birth

MM slash DD slash YYYY

Insurance Effective Date

MM slash DD slash YYYY

Subscriber Group Number

Subscriber Insurance ID

Assignment of Benefits & Release

Consent*

*Consent: I authorize assignment of benefits to Just 4 Kids Pediatrics and authorize previously named clinic to release any information requested to receive payment.

On occasion, you may wish to have your Child brought to the Clinic by someone other than a parent. Please list the names of those individuals who have your permission to bring your child in for assessment and/or treatment. A day care worker of grandparent is an example of someone you would allow to bring your child in. If you do not want anyone to be authorized, please write NONE on the name line and sign at the bottom.

The Child listed in this packet may be brought in for assessment and treatment by the following individuals:

Authorized Individuals

Authorized Name

Relationship to Child

I authorize the release of information to the following person(s)

Signature*

By signing below I also acknowledge that I received a copy of the Financial Policy and Summary of Notice of Privacy Practices (see last two pages in this packet)

This field is hidden when viewing the form

Signature Date

MM slash DD slash YYYY

Medical Record Release (authorization to release medical information and/or medical records)

Patient Name*

First Last

Patient's Date of Birth (mm/dd/yyyy)*

MM slash DD slash YYYY

Authorize

I authorize Just 4 Kids Pediatrics to use or disclose Protected Health Information (PHI) contained in my Medical Records in the following manner:

Person/Institution Sending Data

From:

Phone

From:

Fax Number

From:

Please Release the Following Protected Health Information

All Records

Chart Notes

X-Rays

Labs

Mental Health

Other (specify below)

If Other, please specify

Purpose of Release (e.g., at patient's request)

The Protected Health Information is being used or disclosed for the following purpose(s): (If the patient is requesting the release, this may state "at patient's request")

*Consent: I understand that I have the right to revoke this authorization in writing by sending notification to the address above.

*Consent: I understand that when I revoke this authorization it is not effective to the extent that the clinic has already relied on the use or disclosure of the Protected Health Information.

*Consent: I understand that the Protected Health Information released pursuant to this authorization might be re-disclosed by the party who receives that information and may no longer be protected by federal or state law.

*Consent: The clinic will not base my treatment or payment on whether I provide an authorization for the requested use of disclosure unless the provision of health care is solely for the purpose of creating Protected Health Information for disclosure to a third party.

*Protected Health Information consent: I understand that I have a right to inspect or copy the Protected Health Information to be used or disclosed.

Protected Health Information consen*

*Protected Health Information consent: Agree to right to refuse

If you have any questions concerning this form please contact the clinic manager.

Parent/Guardian Signature (Medical Record Release)*

This field is hidden when viewing the form

Signature Date (Medical Record Release)

MM slash DD slash YYYY

Social Determinants

In our efforts to improve your overall experience, our practice would appreciate you taking some time to answer a few questions

This information assists us in a better patient focused approach to your care

Circle the answer that is most appropriate to your situation.

Child's Name

Today's Date

MM slash DD slash YYYY

Do you have transportation to make it to your medical appointments?

Yes

Do you have a permanent place of residence?

Yes

Do you have concerns that you do not have enough food for your family?

Yes

Do you have trouble paying for your healthcare needs, including prescribed medications?

Yes

Would you like our staff to contact you about any of the following?

Transportation Resources

Housing Resources

Food Resources

Healthcare Cost Assistance

Any additional children

How did you hear about us?*

Idaho Health Data Exchange (IHDE)

Idaho Falls Pediatrics has chosen to participate in the Idaho Health Data Exchange also known as IHDE. If you do not want your child to participate in IHDE and choose not to have their health care information share with other medical providers involved with their care, you can opt out at any time. In order to opt out, you need to complete and sign the IHDE "Request to Restrict Disclosure of Health Information" form and mail or fax it to IHDE. The opt out forms are on our website or you can request one at the front desk. You will receive a letter of confirmation upon completing the form. You will also need to contact directly any facility you wish to also restrict your child's information with. The IHDE form is available at our front desk and online. If you do not complete this form, we may share your child's protected health information with other participating health care providers involved in your care through IHDE interface. This is a very secure statewide internet-based health information exchange, with the goal of improving the quality and coordinataion of health care in the state of Idaho.

Thank you, Idaho Falls Pediatrics

Idaho Falls Pediatrics & Mountain Peak Pediatrics

Financial and Office Policies

Thank you for choosing us as your healthcare provider. We are committed to your children’s treatment being successful. The following is a statement of our financial policy which we require you to read and sign prior to treatment. All patients must complete our information and insurance form before seeing a provider.

Minor Patients

The parent/ guardian or adult (18yrs or older) with written permission from parents must accompany any child under 18 years of age. Any unaccompanied minor will be denied treatment. The parents/ guardian or authorized adult accompanying the minor is responsible for the full payment, copayment or past due balance at the time of service. The parent or legal guardian is giving permission to anyone they list the authority to sign for all assessments and/or treatments at any time provided by the medical providers at Idaho Falls Pediatrics and Mountain Peak Pediatrics.

Insurance

We will file your insurance as a courtesy to you and will do our best to maximize your benefits. It is your responsibility to understand your insurance benefits (what is and what is not covered). All copays are due at the time of service. Some insurance companies may charge a different copay or coinsurance amount when seeing a physician assistant rather than a doctor. Any remaining balance is your responsibility. If there are any questions regarding a claim, please contact your insurance company. After you have contacted your insurance company, if there is anything we can assist you with please contact our billing office.

We do contract with most insurance companies and will take their usual and customary allowances. If however, you have insurance that we are not contracting with, you are responsible for the full remaining balance after the insurance pays.

WE DO NO TAKE ANY OUT OF STATE MEDICAID.

It is your responsibility to update any insurance changes. If you fail to provide us with the correct and complete insurance information in a timely manner, you will be responsible for the payment of a claim. Any patient who has not been seen in our clinic in over three years will be considered a NEW PATIENT.

Uninsured/Self Pay

Payment is due at the time of service with a 20% discount.

International/Exchange Students

Payment is expected at the time of service in full. We do not verify coverage or accept International health plans.

Delinquent Accounts

Payments must be made consistently every month, if not paid in full. If at any time your account is delinquent, your account may be sent to Trust Financial Collection Agency and a 35% fee will be added to the balance. You will not be able to schedule any appointments until the account is paid for in full.

Updated Information

It is your responsibility to make sure all addresses, phone numbers, email, others authorized to have child seen, and insurance policies are kept up to date.

Missed Appointments

Being able to treat our patients is of most concern to us. Therefore, we require a 24-hour notice to cancel or reschedule any appointments so that those children that need to be seen can be. If you have scheduled more than one child at the same time on the same day or have a circumcision scheduled that you do not cancel or reschedule before 24 hours or if you miss that appointment, you will be charged a $50.00 fee. For single scheduled appointments that are missed there will not be a charge for the first one in a calendar year. If there is a second missed appointment in the same calendar year for a single appointment there will be a $15.00 reinstatement fee. If there is a third missed appointment in the same calendar year for a single appointment there will be a $30.00 reinstatement fee. If there is a fourth missed appointment in the same calendar year you may be dismissed from our practice. All fees will be required to be paid in full before we can schedule any future appointments.

Divorced Parents

In the event of divorce, we will try to extend every courtesy to you in dealing with your divorce decree. However, we cannot become party to your decree. Parents are responsible for accurate insurance information, copies of cards, and payments on their accounts. The responsibility of minor’s rests with the accompanying adult or residing parent or guardian. We will not contact the spouse for payment or patient information pertaining to insurance or demographics needed to complete claim submission.

Wellness exams

We require all patients to have a current wellness exam to be eligible to receive medication or referrals. Most insurance companies cover wellness at 100% but it is the parent responsibility to contact the insurance company, if there is a question regarding coverage. As a new patient, if there is a current well check at another providers office, we will need a copy for the chart.

Thank you for taking the time to read and understand our financial policy. Please let us know if you have any questions or concerns.

HIPPA

Summary of Notice of Privacy Practices

The notice of Privacy Practice contains a detailed description of how our office will protect your health information, your rights as a patient and our common practice in dealing with patient health information.

Uses and Disclosures of Health Information

We will use and disclose your children’s health information in order to treat your children or to assist other health care providers in treating your children. We will also use and disclose their health information in order to obtain payment for our services or to allow insurance companies to process insurance claims for services rendered to your children by us or other health care providers.

Finally, we may disclose your children’s health information for certain limited operational actives such as licensing, accreditation and training of students.

Uses and Disclosures Based on your Authorization

We will not use or disclose your health information without your written authorization except as stated in more detail in the Notice of Privacy Practices.

Uses and Disclosures Not Requiring Your Authorization

In the following circumstances, we may disclose your health information without your written authorization:

For purposes of public health and safety
To government agencies for purposes of audits, investigations, and other oversight activists
To government authorities to prevent child abuse or domestic violence
To the FDA to report product defects of incidents
To law enforcement authorities to protect public safety or to assist in apprehending criminal offenders.
When required by court orders, search warrants, subpoenas and as otherwise required by law

Patient’s Rights

As our patient you have the following rights:

To have access to and or a copy of your health information
To receive an account of certain disclosures we have made of your health information
To request restrictions as to how your health information is used or disclosed
To request that we communicate with you in confidence
To request that we amend your health information
To receive notice of your privacy practices

Urgent Care Patient Portal

We Are Here for You

Pediatrics Patient Portal

We Are Here for You

Mental Health Patient Portal

We Are Here for You

Mental Health Info

General Patient Portal

We Are Here for You

New Patient Form

New Patient Form

Patient Information

Insurance Information

Assignment of Benefits & Release

Medical Record Release (authorization to release medical information and/or medical records)

Social Determinants

Idaho Health Data Exchange (IHDE)

Idaho Falls Pediatrics & Mountain Peak Pediatrics

Financial and Office Policies

Minor Patients

Insurance

Uninsured/Self Pay

International/Exchange Students

Delinquent Accounts

Updated Information

Missed Appointments

Divorced Parents

Wellness exams

HIPPA

Summary of Notice of Privacy Practices

Uses and Disclosures of Health Information

Uses and Disclosures Based on your Authorization

Uses and Disclosures Not Requiring Your Authorization

Patient’s Rights