New Patient Registration

New Patient Packet
How Did You Hear About PHA? Check one*

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Which provider are you interested in seeing?*

Patient Information
Note: We use an EMR for all Patient Charts which is HIPAA-Compliant and provides industry-leading data system security. PHA uses a secure patient portal which allows you to instantly access your records online and communicate with your doctor securely.
Date

MonthDayYear
Patient Info*
Patient Ethnic/Genetic Background*
Patient Address*
Is your child registered with the "Texas Immunization Registry"?*

Parent/Legal Guardian Info
Mother Name*
Mother Date of Birth

MonthDayYear
Date
Mother Contact*
Mother E-mail*
Preferred Contact?*

CellEmailYes - Messages can be left on voicemail, text and/or email, pertaining to visits.No - Cell messages, text and/or emails pertaining to visits
Father Name*
Father Date of Birth

MonthDayYear
Date
Father Contact*
Father E-mail*
Preferred Contact?*

CellEmailYes - Messages can be left on voicemail, text and/or email, pertaining to visits.No - Cell messages, text and/or emails pertaining to visits
Emergency Contact Name:
Emergency Contact Number:
Emergency Contact E-mail
Relation to the Patient:

Primary Insurance Information
Primary PCP*
Policy Holder Name*
Policy Holder DOB*

MonthDayYear
Patient's Relation to Insured*
Insurance/Plan Type*
Date Insurance is effective*

MonthDayYear
Insurance Plan*
Subscriber ID #*
Group #*
Insurance Company Contact #*
Do you have a secondary insurance?*

YesNo

Secondary Insurance Information
Policy Holder Full Name
Policy Holder DOB

MonthDayYear
Patient's Relation to Insured
Insurance Plan
Subscriber ID #
Group #
Insurance/Plan Type
Date Insurance is effective

MonthDayYear
Date
Insurance Company Contact #

Child Health & Development
How was your child's health in the first year?

PoorFairGoodExcellentUnknown
At what age did your child first:
Sit Up?
Crawl?
Walk?
Talk?
Describe your child's sleep pattern? Time to bed, awake, naps, nightmares?
How would you describe your child's temperament?
How would you describe your child's behavior and performance at school?

Cancellation Policy
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NO SHOW or CANCELLATION FEES: $50.00 fee applies to all Well Child Visits and ADD/ADHD visits, cancelled less than 24 hrs prior to appointment or No Show to appointments. $25.00 fee applies to all other No Show appointments.
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Missed appointments will be invoiced at full cost of the above explained fees. Extenuating circumstances will be reviewed on a case-by-case basis. A strict twenty-four hour (1 full business day) notice via voice mail and email are acceptable. Advance notice allows us to better accommodate our clients on the waiting list. Thank you for your cooperation

Disclosure of Personal Information
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Privacy of your personal health information (HIPAA) is an important, while providing you with quality natural pediatric care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We will try to be as open and transparent as possible about the way we handle your personal information. All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are trained in the appropriate use and protection of your information. All electronic forms and consent forms are viewed only by PHA staff, unless you have specifically signed a Release of Records to make these forms available to another Health Care Provider or family member. In-office forms are utilized by the staff of the center and adhere to the appropriate use and protection of your information. Our Privacy Policy at PHA outlines what we are doing to ensure that: Only necessary information is collected about you; We only share your information with your consent; Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols; Our privacy protocols comply with privacy legislation and standards of our regulatory body, the AAP. How our Clinic Collects, Uses and Discloses Patients’ Personal Information: PHA understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined how the clinic is using and disclosing your information.
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The clinic will collect, use and disclose information about you for the following purposes: To assess your health concerns / To provide health care to advise you of treatment options / To establish and maintain contact with you / To send you newsletters and other information mailings / To remind you of upcoming appointments / To communicate with other treating health-care providers / To allow us to efficiently follow-up for treatment, care and billing / To complete claims for insurance purposes / To process credit card payments / To comply with all regulatory and legal requirements including court orders, statutory requirements to advise authorities of child abuse and reporting diseases and individuals who may be an imminent threat to harm themselves or others.
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I authorize release of copies of medical records to providers outside of PHA who are being consulted with and/or I am being referred to in connection with my current treatment, to insurance companies for the purpose of determining benefits for services provided, and to reference laboratories for billing purposes.
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I have reviewed the above information that explains how PHA will use my personal information and the steps that the center / clinic is taking to protect my information. I agree that PHA can collect, use and disclose personal information as set out above in the information about the clinic privacy policies.

Financial Policy
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Payment is due regardless of who brings the child in for the service, Grandparents, caregivers, aunts, etc., payment is expected. For separated or divorced parents, payment is still expected at the time of service, we will not bill the other parent. You are welcome to call the other parent at the time of check out.
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Insurance must be provided and active in order to utilize your benefits. If insurance cannot be determined to be an active policy, the patient will be considered Private Pay for that visit. Financial responsibility is determined from the benefits we receive from your insurance company. Your insurance determines if you have a copay, deductible and/or co-insuranceVerification of insurance is not a guarantee of payment; you are still responsible for all services provided to your child, until your insurance processes and pays PHA for our services. Acceptable forms of payment include cash, check, Visa, MasterCard and Discover. PHA is willing to offer payment holds or payment plans on larger balances.
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Forensic Services Fees - A per hour fee in the amount of $300.00 staff and $400.00 physician will be charged directly to the parent/guardian for any court testimony regarding forensic services for divorce and child custody cases.

Medical Informed Consent
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AUTHORIZATION FOR TREATMENT: I authorize PHA to provide treatment to the named patient in this electronic document. REFERENCE LABORATORY SERVICES: I understand that PHA utilizes the services of an outside lab to perform some of the lab tests requested by its physicians. I further understand that the Reference Laboratory will bill separately for its services. I consent to PHA and providing demographic information as necessary for billing purposes. ASSIGNMENT OF BENEFITS: I authorize my insurance company to pay and hereby assign directly to PHA all benefits, if any, otherwise payable to me for services. This authorization may be revoked by either me or my insurance company at any time in writing. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION: I authorize release of copies of pertinent medical records to providers outside of PHA who are being consulted with and/or I am being referred to in connection with my current treatment, to insurance companies for the purpose of determining benefits for services provided, and to reference laboratories for billing purposes. AUTHORIZATION FOR RELEASE FOR QUALITY IMPROVEMENT: Texas Law requires us to inform you that a copy of your medical record, no matter when created, may be released to outside groups for medical research or quality improvement purposes unless you object. Researchers cannot use patient names or identifying characteristics when reporting any results of their research. We evaluate these requests to ensure that the release of patient records is necessary to accomplish the research purpose. AUTHORIZATION FOR REVIEW OF PRESCRIPTION HISTORY: I authorize PHA to access my electronic records of previously prescribed medications through the external electronic prescribing network, sure scripts.
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I understand PHA utilizes the services of an outside lab to perform some of the lab tests requested by its physicians. I further understand that the Reference Laboratory will bill separately for its services.

Communication Consent
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This section is in accordance with the New Anti-Spam Legislation that came into effect July 1, 2014 In order to contact patients about clinic changes, promotions, products, events, newsletters, workshops and programs, we require your consent below. You may choose to withdraw consent at any time and you will no longer receive emails from PHA by email or in writing. To better serve our patients, our office has established a Patient Portal, for some forms of communication. The Patient Portal is a simple way to access your child’s health information online. In addition, the Patient Portal allows you to: • View and request appointments • View and print immunization records for school and day care • Request prescription refills • Retrieve test/lab results • View billing statements and balance • Make secure credit card payments for balances• Communicate with our office by sending and receiving secure messages regarding lab results, medical questions, medication refill request, referral requests. I understand that this office will not be responsible for information loss, delay or breaches in confidentiality that are due to technical factors beyond this office's control. I understand and agree to the above electronic communications policy. By signing below, you are agreeing that we may send medical related correspondence to you via email, and that we may respond to your emails to us via email.

Vaccine Consent

PHA follows vaccination according to the CDC & AAP standard Recommended Child and Adolescent Immunization Schedule for ages 18 years or younger.
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I understand that by signing this form, I give consent for my child to receive recommended immunizations as per the CDC Immunization Schedule, including the influenza vaccine. I understand that each vaccine will be discussed with me prior to administration. I understand that I may address this issue with my child’s doctor or nurse at any time and that I may re-visit decisions on immunization for my child anytime in the future.I understand that Pediatric Healthcare Associates does not take-on new patients that do not follow the CDC & AAP standard recommendations regarding vaccinations.

Telehealth Consent
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PHA will file a claim to your insurance provider for the telehealth appointment. Most commercial insurance plans are covering telehealth appointments at the same benefits as an office visit. PHA will send a statement for any balances after insurance processes the claim for payment. I understand that I will be responsible for any out-of-pocket costs such as co-payments or coinsurance that apply to my telehealth visit
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Your Rights Given that your consent to this telehealth consultation is voluntary, you have your right to withhold or withdraw your consent at any time. By your withholding or withdrawal, your relationship with us will not be affected with regard to your future treatment and/or consultation with us in the future. You are still entitled to other benefits that do not need your consent.

Parent/Legal Guardian Signature*

Clear
Should be Empty:

New Patient Packet

Patient Information

Texas Immunization Registry (Minor)

Parent/Legal Guardian Info

Primary Insurance Information

Secondary Insurance Information

Child Health History

Child Birth History

Child Health & Development

Cancellation Policy

Disclosure of Personal Information

Financial Policy

Medical Informed Consent

Communication Consent

Vaccine Consent

Telehealth Consent