Signature of Person Completing This Form:
Patient's Birth Weight Pounds* Ounces*
Parent/Guardian Signature Signature* Relationship to Patient
CELEBRATION PEDIATRICS ASSOCIATES, P.A. AUTHORIZATION TO RELEASE OR USE INFORMATION FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS
I (GUARDIAN LISTED ABOVE), hereby authorize the release or use of my dependents individually identifiable health information (PHI "Protected Health Information") and medical record information by Celebration Pediatrics Associates, PA, in order to carry out treatment, payment, or health care operations on behalf (THE PATIENT LISTED ABOVE) Associates, PA Notice of Privacy Practices for a more complete description of the potential release and use of such information. You have the right to review such Notice prior to signing this consent from.
We reserve the right to change the terms of the Notice to Privacy Practices at any time. If we do make changes to the terms, you may obtain a copy of the revised notice.
You retain the right to request that we further restrict how your dependent's PHI is released or used to carry out treatment, payment, or health care operation. Our practice is not required to agree to such requested restriction: however, if we do agree to your requested restriction(s), such restrictions are then binding on the practice.
I acknowledge and agree that the practice may disclose my dependent's PHI and medical record information, confirm or change appointment times and speak to the office on my dependent's behalf with the following individuals who are family members, legal representatives, guardians, healthcare surgeons, or have power of attorney:
Any additional individuals can be requested to be added. I agree and have been given notice that the practice may also disclose the following types of information contained in my dependent's medical record to the appropriate authorities as we are required by Florida State Law 384.25
(PLEASE INITIAL ALL CATERGORIES BELOW:)
HIV/AIDS Information: Initial * Mental Health Information: Initial * Substance Abuse Information: Initial * Sexually Transmitted Disease Information: Initial * ** If the patient is under the age of 18, Pregnancy Information: Initial *
I understand that if the practice needs to contact me, it will be via the primary phone number listed in my guarantor file. I always agree to keep this number updated and understand that my dependent's demographics are my responsibility. I acknowledge that I can update demographics through several sources. I can update them in the office directly, through a call to the office, or through my dependent's patient portal. Should the practice need to communicate with me and my phone is unavailable, after 3 attempts a certified letter will be sent through the mail. I elect for correspondence to be directed to me in the optional form of:
At all times, you retain the right to revoke this consent. Such revocation must be submitted to the practice in writing. The revocation shall be effective to the extent that the practice has already taken action based on the prior consent.
The practice may refuse to treat your dependent if you (or an authorized representative) do not sign this consent form. If you (or an authorized representative) sign this consent and then revoke it, the practice has the right to refuse to provider further treatment to you as of the time of the revocation (except to the extent that the practice is required by law to treat individuals
I have read and understand the information in this consent. I have received a copy of this consent and I am the authorized party to act on the behalf of the patient to sign this document verifying
Parent and/or Guardian's Signature:
Parent and/or Guardian's Signature: Signature*
Insurance: If you have insurance, we will provide insurance claim filing for the insurance plans with which we participate; however, if we do not accept your insurance plan or if a claim is denied or a balance is due, you are responsible for payment of the balance owed and we expect payment within 30 days from the date we notify you of such determination. It is your responsibility to pay any co-pay's, deductible, co- insurance or any other balance not paid for by the insurance or third-party payer within 30 days.
It is the responsibility of the patient/guardian to provide us with current insurance plan information prior to services rendered in order for accurate billing of services to be filed. You are also responsible for contacting your insurance company to make sure we are in network with your particular plan. It is important that you are familiar with the guidelines of your plan requirements regarding authorizations, deductibles, co- payments and other vital requirements.
In consideration of services rendered, you agree to transfer and assign to Celebration Pediatrics all rights, title and interest in any payment due to you or otherwise payable to you for services rendered.
Self-Pay: In consideration of the services rendered, you agree to pay Celebration Pediatrics in accordance with the regular rates and terms of service/costs for Celebration Pediatrics. Payment is due in full at the time services are rendered. You affirm that you are duly authorized as the patient or as patient's guardian/agent to execute this document and accept its terms.
Medicare/Medicaid: Patient's certification authorization to release information and payment request. You certify the information given to Celebration Pediatrics in applying for payment under Title XVIII/XIX of the Social security act is correct. You authorize any holder of medical or other information about you to release to Social Security Administration/Division of Family services or its intermediaries or carriers any information needed for this or a related Medicare/Medicaid claim. You further certify all insurance proceeds pertaining to treatment or services provided shall be assigned to Celebration Pediatrics.
Laboratory Charges: We collect and send specimens to a laboratory for processing. We are NOT responsible for laboratory charges. If you have any questions regarding the laboratory charges, you must call the laboratory listed on your bill.
Credit Cards: For your convenience, we will keep your credit card information on file to be used for balances on your account that are your responsibility (co-insurances, co-pays, and deductibles, not to exceed $150.00.
FMLA: There is a $25 fee for FMLA paperwork that is processed withing 7 business days. This fee is due PRIOR to any paperwork being faxed or picked up. There is a $50 fee for expedited FMLA paperwork.
Returned Check Fee: A $35.00 fee will be assessed to your account for any returned checks. No Show Policy: A $25.00 fee will be assessed to your account for any "NO SHOW" or CANCELLATION on a same day SICK appointment. All future appointments require a 24-hour cancellation notice PRIOR to the appointment, or the $25.00 fee will apply.
Tele-Care Call Policy: All calls after normal business hours requesting medical advice will be referred to the Arnold Palmer's Tele-Care Nurse Program. There is a $20.00 fee per call for this service. This fee is YOUR responsibility. This service is NOT covered by any insurance plan.
Colletions/Past Due Accounts: You understand and agree that all accounts must be brought current within 30 days of the service that was rendered. Should your account lapse past the 30 days your account will placed in a collections status and be transferred to our outside collection agency if payment in full or payment arrangements are not made.
You authorize Celebration Pediatrics and hereby give all of its affiliated entities, employees, agents and Independent Contractors permission to call you through the use of dialing equipment artificial voice or similar technology, even if you are charged for the call. You expressly agree that such automated calls may be made by Celebration Pediatrics and all of its ffiliates, contractors and agents. With such consent, you specifically waive any claim you may have against Celebration Pediatrics, its affiliates, contractors and/or agents for making such calls, including any claim under the Telephone Consumer Protection Act. You also expressly agree that this provision applies to the use of text messaging. You authorize Celebration Pediatrics, its affiliates, contractors and/or agents to use any cell phone or other telephone number to contact you for any purpose, including collection of an outstanding invoice at the number set forth below. If you have a change in address or telephone number, it is your responsibility to provide Celebration Pediatrics with your updated contact information.
INSURANCE: Initial* SELF-PAY: Initial* MEDICARE/MEDICAID: Initial* LABRATORY CHARGES: Initial* OFFICE CHARGES: Initial* COLLECTIONS/PAST DUE ACCOUNTS: Initial*
I have read, understand and agree to Celebration Pediatrics' Billing and Financial Policy:
An annual exam or well check visit is a routine check-up, which includes obtaining a weight, height, blood pressure check, vision screening and exam by physician. Your provider may also order some screening exams such as lead and hemoglobin, hearing screen, or other studies as indicated.
A problem or "sick" visit focuses on discovering and evaluating problems. Examples could be congestion or cold symptoms, depression, anxiety or a skin condition such as acne.
Each of these visits has their own procedure code which is used to file claims with your insurance company. The insurance company determines their own reimbursement for physician services.
Sometimes during a well exam, a problem is identified based upon a patient's present medical complaint, or when the physician discovers abnormalities during the visit through the exam or review of the patient's history. If this happens, the physician may need to initiate an evaluation of the problem and file a claim for both types of visits on the same day.
Coding rules set by the health insurance industry specifically state: "if an abnormality is encountered or a pre-existing problem is addressed in the process of performing this preventative medicine evaluation service, then the appropriate visit code should also be reported. This is not double billing but is correct coding procedure. This may also save the patient another trip to the office later. Our goal is to address every patient's health concern as thoroughly and efficiently as possible. Sometimes this can be done at the same time as the well exam, thus eliminating the need for an additional visit. However, insurance companies will still require the same co-pays or apply the same deductibles as would be required for a separate visit. (Please keep in mind some conditions may elicit an additional follow-up to address certain conditions or concerns. Your physician will determine this at the time of the visit if indicated.)
Parent and/or Guardian Signature: Signature*