GRAHAM PEDIATRICS OF WOODSTOCK 105 Mirramont Lake Drive, Woodstock. Ga 30189 Phone 770 -485-9670, Fax 866-698-9350, www. grahampediatrics.com
PATIENT REGISTRATION FORM
Patient Information *
(If more than one child register here)
Policy Holder (Primary Insurance)
FINANCIAL/PRIVACY POLICIES (HIPPA)
By signing below, I authorize and acknowledge each of the following:
• I authorize Graham Pediatrics of Woodstock (GPOW) to evaluate and treat the above name(s).
• I authorize GPOW to use/release my medical information for treatment purposes to other physicians, specialists, health care providers etc. and billing information to insurance companies so that payments for charges can be processed and paid directly to GPOW.
• I acknowledge that I am financially responsible for copays, deductibles and co-insurances and any other services that are not covered by my insurance plan or for any outstanding balances on patient’s account at the time of service. I will also be financially responsible for the visit at the time of service if I don’t show proof of an active insurance.
GRAHAM PEDIATRICS OF WOODSTOCK105 Mirramont Lake Drive, Woodstock. Ga 30189Phone 770-485-9670, Fax 866-698-9350, www. grahampediatrics.com
Financial Responsibility Form
Graham Pediatrics of Woodstock (GPOW) partners with you to take care of your child. We would like to take the time to clarify our expectations of your responsibilities, please read and sign, acknowledging your understanding of our financial policies.
For each visit please bring your:
Private Insurance (Newborns/Patients)
Medicaid Insurance (Newborns/ Patients)
Coinsurance: As a courtesy we bill co-insurance, after your insurance has processed your claim.
Coordination of benefits: If you have two health insurances, it is your responsibility for you to call each insurance and do “coordination of benefits” this means that each insurance knows that you have another insurance. Please make sure that we are in-network with both insurances, otherwise your claims will be denied, and you will be financially responsible for any balance generated from these denials.
Combined visits: If you are scheduled for a well child exam, and other health concerns are brought up that would typically require a sick visit, your insurance company may consider these two separate visits and generate a statement for your copay and other charges accordingly.
By signing below, you agree to accept full financial responsibility as a patient who is receiving medical services, or as the responsible party for minor patients. Your signature verifies that you have read the above disclosure, understand your responsibilities, and agree to these terms.
Child Information *
We firmly believe in the effectiveness of vaccines to prevent life threatening illnesses and to save lives. We firmly believe based on all available literature, evidence, and current studies that vaccines, preservatives or a combination of the two do not cause autism or other developmental disabilities. Please be advised that by not vaccinating on the given schedule, you are putting your child at unnecessary risk for life-threating illnesses and disabilities, and even death.
Our expectation for new and existing patients is to vaccinate according to the given schedule by the Centers for Disease Control or the American Academy of Pediatrics including the MMR vaccine. If you do not plan on vaccinating according to this policy, we advise you to find another provider who shares your views. Furthermore, we do not offer alternative schedules as this puts your child at further unnecessary risk of infection.
By signing this form, I agree to have my child fully vaccinated in a timely manner as scheduled by the Centers for Disease Control or the American Academy of Pediatrics. I understand that otherwise I have chosen for my child to NOT be a patient at this practice.
CONSENT TO TREATMENT
I hereby authorize for my child(ren) to be medically evaluated and treated by the providers of Graham Pediatrics of Woodstock as well as staff and designees. I understand that treatments and services may include, but is not limited to: lab tests, vaccines, screening exams, diagnostic testing, and routine physicals.
This authorization will remain in effect until revoked in writing.
NON-PARENT CONSENT FORM
We require the consent of a parent/legal guardian to provide medical care for patients under the age of 18 and when a parent/legal guardian is not present. I authorize Graham Pediatrics of Woodstock (GPOW) and its personnel to deliver routine medical care to my child(ren) listed below, this includes but is not limited to consent for necessary medications, vaccinations, and procedures. I understand that I can revoke this authorization for any or all of these individuals at any time.
Children covered by this consent (list full names and date of birth)
I authorize the following individual(s) to bring in my children to their appointments:
Our goal is to provide quality medical care in a timely manner and to serve your child’s medical needs. Graham Pediatrics of Woodstock prefers to work only by appointments to serve you better.
- For scheduled appointments: After 3 no shows/cancellations (less than 24 hours prior to your appointment), you have chosen to find another provider.
- For same-day appointments: After 3 no shows/cancellations (less than 2 hours prior to your appointment), you have chosen to find another provider.
-Rescheduled Appointments: After 5 consecutives short notice reschedule, you have chosen to find another provider
Please CALL our office:
Our office makes reminder calls for your appointment. This is done as courtesy to you. It is your responsibility to confirm and to attend to your appointment as scheduled.
I acknowledge that I have been given the opportunity to read the Notice of Privacy Practive Policy for Graham Pediatrics of Woodstock (GPOW) and I can access it through the GPOW website under Forms & Insurances and Privacy Statement.