Intake Over 18 PPO-HMO

Patient Registration

Intake Form for Patient age 18 and older. Encrypted and HIPAA compliant.
Patient Data

This form is encrypted and HIPAA compliant.
Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Date
Sex *

Male Female N/A
Cell Phone # *
Home Tel. #
Email Address *
example@example.com
Home Address *

Street Address

Street Address Line 2

City State

Zip Code
Social Security #
Preferred Pharmacy Name & Address
e.g.: CVS 3010 S. Sepulveda Blvd. Los Angeles, 90064
School or Occupation
Preferred Language
Race(s)
Ethnicity
Emergency Contact
Name

First Name Last Name
Cell Number
Home Tel. Number
Relationship to Patient
Insurance Information
Please select one: *

I have PPO insurance and I have verified that California Kids Pediatrics is IN NETWORK with my plan. I have HMO insurance and I have verified that California Kids Pediatrics is IN NETWORK with my plan. I don't have insurance, OR California Kids Pediatrics is not in network with my insurance. I am responsible for payment at the time of visit.
Insurance Company *
Insurance Address for Submitting Claims:

LOCATED ON THE BACK OF YOUR INSURANCE CARD

Street Address Line 2

City State

Zip Code
Policy # *
Policy Holder's Name *
Policy Holder's Date of Birth *

Month Day Year
Date
Address of Policy Holder (If different from Patient)

Street Address

Street Address Line 2

City State

Zip Code
Patient Relationship to Policy Holder
Ex: Child
Group #
How did you hear about us?
Notice to Consumers

Medical Doctors are licensed and regulated by the Medical Board of California. (800)633-2322

www.mbc.ca.gov
2990 S. Sepulveda Blvd. Suite 202 Los Angeles, CA 90064

T. 424-277-2020 F. 310-388-1104 www.CalKidsPeds.com

Patient Registration Cont.
Medical Consent
I hereby authorize examination, vaccination and any services deemed necessary by California Kids Pediatrics, Leila Bozorgnia M.D., Marna Geisler M.D. and associates.
Name *

First Name Last Name
Signature *

Clear
Date *

Month Day Year
Date
Financial Information and Authorization
Any deductible, co-payment, co-insurance or balance is due at the time of visit before consultation with the Doctor.

Insurance health plans create networks that certain providers are selected to be a part of. We may be IN NETWORK with some plans offer by an insurance company; however, we might not be IN NETWORK with the type of plan you have. It is the patient’s responsibility to confirm if we are IN NETWORK with your health plan. If our office is in network with your insurance, the patient is still fully responsible for services rendered. Your insurance may not cover the services or may only partially cover them. The office can make no guarantee of actual payment by your insurance company. Even though an insurance claim has been filed, you may still receive a statement each month from our biller who will provide you with the outstanding balance due on the account, since you, not the insurance company is ultimately responsible for payment on the account. It is the parents, guardian or patient’s responsibility to provide the office with any new or updated information when it comes to new insurance, change of address, phone numbers or credit card information. Our office will be keeping credit card information on file. The office will continue to mail out and email statements. You will have the option to self-pay online, pay in person, mail in a check or pay over the phone by contacting the office. If we do not receive payments after two months, we will automatically charge your credit card on file with an additional $10 fee.

I authorize the release of any medical information to my insurance carrier that is necessary for processing of claims. I authorize payment of medical benefits directly from my insurance carrier to California Kids Pediatrics, Leila Bozorgnia, M.D., Marna Geisler, M.D., for services provided.
Name *

First Name Last Name
Signature *

Clear
Date *

Month Day Year
Date
Email
I understand that Dr. Leila Bozorgnia and Dr. Marna Geisler are available by email for non-urgent matters only. Non-urgent matters will be addressed within 3 business days. If you do have an urgent matter, please call the office at 424-277-2020.
Name *

First Name Last Name
Signature *

Clear
Date *

Month Day Year
Date
Appointment Cancellation Policy
We appreciate that most patients make their appointments well in advance and show up on time, but not infrequently, some families arrive very late, or do not show up at all for an appointment without prior notice. Lateness makes it difficult for other patients who have arrived on time to be seen in a timely manner. Not showing up at all prevents the office from scheduling another patient and deprives another family the opportunity to receive medical care. To alleviate this problem, we have a policy in which we ask that any patient who cannot make it to the appointment cancel at least 24 hours prior to the scheduled time. There will be a $75 charge per patient who does not show up for an appointment without prior cancellation. We understand that there are always extenuating circumstances so we apply this policy judiciously.

By signing this agreement you acknowledge notice of our office policy regarding a $75 fee charged for missed appointments and agree to accept the terms of this policy, regardless of the type of insurance plan you may have. Further, you are stating that you clearly understand your obligations to cancel appointments at least 24 hours in advance.
Name *

First Name Last Name
Signature *

Clear
Date *

Month Day Year
Date
Notice of Privacy Practices Acknowledgement
I understand that, under the Health Insurance Portability& Accountability Act of 1998 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan and direct my treatment and follow up among the multiple healthcare providers who may be involved in the treatment directly and indirectly.

• Obtain payment from third-party payers.

• Conduct normal healthcare operations such as quality assessments and physician certifications.

I acknowledge that I may request your Notice of Privacy Practices containing a more complete description of the uses and disclosure of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or other health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
Name *

First Name Last Name
Signature *

Clear
Date *

Month Day Year
Date
Please verify that you are human *
Should be Empty:

Patient Registration

Patient Data

Emergency Contact

Insurance Information

Patient Registration Cont.

Medical Consent

Financial Information and Authorization

Email

Appointment Cancellation Policy

Notice of Privacy Practices Acknowledgement