• Welcome to our practice. We are dedicated to providing quality personal health care to each of our patients. In order to facilitate your first visit, please complete paperwork prior to your scheduled appointment. Due to the additional time our staff requires to prepare your chart for your first visit, we ask that you arrive 30 minutes prior to your scheduled appointment. Failure to arrive within this time will result in rescheduling of your appointment. Please have your completed paper work, your child's insurance card and picture identification available when you arrive for your appointment.

    There will be a $50.00 charge for all appointments that are not kept or are cancelled with less than 24 hours notice.

    AS a courtesy to our patients, we will verify your insurance benefits prior to or on your first visit. This will indicate covered services and your financial responsibility. Co-payments or coinsurance's are due at the time services are rendered. Failure to provide you co-payments upon each visit will result in rescheduling your appointment. For your convenience we accept cash, personal checks, MasterCard, Visa, Discover, and American Express. A $35.00 charge will be applied to all returned checks.

    Our physician cannot assume any responsibility for you medical care until you have become an established patient. Therefore, no prescriptions, diagnostic testing or treatment can be given at your initial visit.

    Thank you for choosing our practice to meet your medical needs. Our goal is to provide you with the best medical care available in a relaxed and warm atmosphere.

  • Clear
  •  /  /
    Pick a Date
  • Please answer all questions fully

  • 7635 ASHLEY PARK CT SUITE 501

  • ORLANDO, FL 32835-6196

  •  /  /
    Pick a Date
  • Responsible Party Name (Last, First ,MI)

  •  /  /
    Pick a Date
  •  /  /
    Pick a Date
  •  /  /
    Pick a Date
  •  /  /
    Pick a Date
  • I certify the information that I have provided is correct. I authorize the release of medical information necessary to process insurance claims to insurance companies or their agencies (including Medicare), for purpose of filing and payment of medical claims. I authorize payment of medical benefits to the provider. I ACKNOWLEDGE THAT INTEREST OR A FEE, AT THE PROVIDER'S CURRENT RATE, MAY BE CHARGED on all balances owing to the provider that are past due.

    I permit a copy of this release to be used in place of the original.

  • Clear
  •  /  /
    Pick a Date
  • For all Your Growing Needsiundermere Pediatrics

    You must notify us of any changes in your insurance

    This is the only way to ensure all lab tests and claims are filed/or billed correctly. It is the parent's responsibility to be sure the correct information is in your child's chart. Any charges accrued due to incorrect information will be bill to you, the parent.

  • The operating hours of Windermere Pediatrics DO NOT include Saturdays. If you feel your child has an urgent medical need on a Saturday, you may contact our office and arrange to have your child seen by the physician on call.

    It is important for you to note that an additional after hour charge of $30.00 is billed to you child's account for this service.

    Some insurance carriers may deny this claim as non-urgent or not covered through your plan.

    If your child is seen in our office on Saturday, you will be financially responsible for the additional $30.00 charge.

    Please sign your acknowledgement and acceptance below.

  • Clear
  •  /  /
    Pick a Date
  •  /  /
    Pick a Date
  • windermere For all Your Needs! Pediatries

    FOR USE AND DISCLOSURE OF PROTECTED HEALTHINFORMATION

    In connection with the medical services my child is receiving from Windermere Pediatrics, I consent to and authorize the physicians and their staff to use and disclose any and all Protected Health Information (PHI) necessary to carry out treatment, Payment and healthcare operations (TPO) related to my child's medical care. I understand the Notice of Privacy Practices is available from the receptionist and that it offers a more complete description of uses and disclosures. This of ffice reserves the right to review and change our Notice of Privacy Practices at any time. Windermere Pediatrics may call my home or office and leave a message in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my child's healthcare. I have the right to request that this practice restricts how they use of disclose my protected health information (PHI) to carry out treatment, payment, and healthcare options (TPO However this office is not required to agree to my request restrictions but if they do the office is bound by this agreement. By signing this form I consent to the use and disclosure of my child's PHI to carry out treatment, payment and health care operations (TPO This consent may be revoked by submitting a request in writing. If I decline to sign this consent, this practice may decline to provide my treatment.

  • Clear
  •  /  /
    Pick a Date
  • Ginny Guyton, MD Marc Feldman, MD Denise Serafin, MD

    WINDERMERE PEDIATRICS 7635 ASHLEY PARK CT. SUITE 501 ORLANDO, FL. 32835

    Amber Eastwood ARNP Larissa Negron, MD Maryann Dunn, ARNP

  • I hereby authorize the personal health information pertaining to my child to be obtained or released. I understand that these records may contain information including psychological, psychiatric, treatment.alcoholic substance abuse, HIV/AIDS results, testing and/or other information regarding diagnosis and

  • MEDICAL RECORDS RELEASE

  • Patient's Name: Patient's Date of Birth:

  •  /  /
    Pick a Date
  • OBTAIN RECORDS FROM:

  • RELEASE RECORDS TO:

  • Reason for records: Please check the specific records needed: All Medical Records Lab ResultsPt. History/Physical; Last 3 Office Notes; Growth Chart; Immunization Record Other

  • Clear
  •  /  /
    Pick a Date
  • Initial History Questionnaire

  • ID NUMBER

  • FORM COMPLETED BY

  •  /  /
    Pick a Date
  •  /  /
    Pick a Date
  • Please list all those living in the child's home.

  • Do you consider your child to be in good health?

    Does your child have any serious illness or medical condition?

  • Has your child had serious injuries or accidents?

  • Has your child had any surgery?

  • Has your child ever been hospitalized?

  • Is your child allergic to any medicines or drugs?

  • Are you concerned about your child's physical development?

  • American Academy of Pediatrics DEDICATED in THE HEALTH OF ALL CHILDREN

  • Initial History Questionnaire

  • Have any family members had the following:

  • Does your child have, or has he/she ever had:

  • Thyroid or other endocrine problem

  •  
  • Should be Empty: