New Patient Registration & Office Policies

PARENT INFORMATION

DO NOT COMPLETE IF THE PATIENT IS 18 YEARS OF AGE OR OLDER
Parent/Legal Guardian #1

This is the parent responsible for the medical bills and the insurance plan subscriber.
Name

First NameLast Name
Birthday

MonthDayYear
Date
Relationship to Patient(s)
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does the above patient(s) live at the above address?
Home or Cell Phone Number
Email Address
example@example.com
Occupation & Employer
Work Phone Number
Parent/Legal Guardian #2
Name

First NameLast Name
Birthday

MonthDayYear
Date
Relationship to Patient(s)
Home Address (if different from Parent/Legal Guardian #1)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does the above patient(s) live at Parent #2's home address, if different from Parent #1 address?

YesNo
Parent #2 Home or Cell Phone Number
Please enter a valid phone number.
Parent #2 Occupation & Employer
Work Phone Number
Please enter a valid phone number.

Full name of parent who is the subscriber for the medical insurance plan or is responsible for the billing statements.
Are there any legal restrictions that would restrict a parent or legal guardian from obtaining information about the patient's health information and medical records?

Yes, If yes, please explain and provide a copy of any legal paperwork that supports this restriction.NoNot applicableOther

EMERGENCY CONTACTS

Please provide emergency contacts that are NOT THE PARENTS.
Emergency Contact 1 Name

First NameLast Name
Relationship to Patient
Emergency Contact 1 Phone Number
Emergency Contact 2 Name

First NameLast Name
Relationship to Patient
Emergency Contact 2 Phone Number
Please enter a valid phone number.

PREFERRED PHARMACY
Name*
Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Member Dues

Quality and personalized pediatric care when you need it.
We thank you for your interest in joining the Friendly Hills Pediatrics family! We are an independent, private, pediatric medical facility.

Our mission is to provide superior access to high-quality and compassionate medical care when families need it most. These concierge-like services are not generally covered by health insurance plans. To receive the perks of this model of care, a membership to our practice is essential to support these services.

Membership includes:
- Personalized care
- Easy access to a Board-Certified Medical Doctor
- Same or next-day appointments
- Telemedicine care
- Secure texting
- Patient portal in our Electronic Medical Record
- Clean, modern office
- Wonderful staff
Please note that, as with other medical practices who accept health insurance, when your child receives care, it is expected that you pay for the portion that you are responsible for, at the time of the visit. As a courtesy to you, we will bill the patent's medical insurance for the office visit.

We hope you feel that our practice is a good fit for your family. We look forward to building a long-lasting relationship with you and your child.

The following are the annual membership dues:

Birth to 5 years: $125

6 and up: $100

The maximum yearly dues for a family with more than two children is $300.

The dues are used to support the specialized level of care and personalized, positive experience for your child. In the long run, your child’s health will benefit from easy, comforting medical visits.

Please note that the annual member dues are a non-contractual fee, are non-refundable, and are not covered by health insurance plans.
Please sign to confirm you understand and agree the annual membership dues.

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Transfer of Care and Medical Records
We require that you bring your child's pertinent medical record to your child's first appointment in our office or have the records sent to us before the first scheduled appointment. Medical records include your child's most recent wellness check, immunizations and any specialist record(s).

We are happy to assist you with requesting records from your child's former pediatrician's office, or from a specialist.

If the records need extensive review, as determined by our staff and/or your child's new pediatrician, an appointment will necessary for this review of medical records. The appointment may be done as a telemedicine, when appropriate. This policy applies for any future specialty referrals, as deemed necessary by our office.

The purpose of this type of appointment is to better understand your child's health and to assist families who have questions not answered by their specialist(s). Any fees associated with that visit will apply, as per usual. We hope that you understand and come to appreciate the purpose of this policy.
Please sign to confirm you understand and agree to the above office policy.*

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COPAYMENTS & DEDUCTIBLES
We participate with most insurance plans. Each insurance policy is different. Therefore, it is important to review your benefits and know what your payment obligations will be at the time of service.

Depending on your insurance policy, a copayment and/or deductible may be required at the time of service. These payments are expected to be made at the time of service. We accept cash, credit cards, Health Savings Account (HSA) cards for payment.

Please note that the copayment is a contractual requirement from your insurance company and cannot be written off by our clinic.
Please sign to confirm you understand and agree to the "Copayments & Deductibles" office policy.*

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NO SHOW FEES
We require notice of at least one business day for all cancellations. Failure to notify the clinic within one business day will result in a no-show fee of $40. Repeated no-shows will result in the family being advised to transfer care out of the practice.
Please sign to confirm you understand and agree the "No Show" office policy.*

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DIVORCED PARENTS AND CUSTODIAL ARRANGEMENTS
Friendly Hills Pediatrics does not get involved in disputes between divorced, separated, or custodial parenting arrangements regarding financial responsibility for their child's medical expenses.

By signing as guarantor below, you agree to be financially responsible for the care we provide to your child, regardless of whether a divorce decree, custodial or other arrangement places that obligation on your former spouse or the child's other parent. We will be happy to provide receipts for paid medical bills for you, as requested.
Please sign to confirm you understand and agree to the "Divorced Parents and Custodial Arrangements" office policy.*

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CREDIT CARD ON FILE
We are committed to making our billing process as simple and easy as possible. We require that all members provide a credit card on file with our office. The credit card is scanned into CardConnect, a secure Merchant Services site.

For security reasons, only the last four digits will be visible to our staff. Credit cards on file can be used to pay copays and other charges deductible fees and services not covered by your health insurance plan.

Once processing the visit with your insurance, you owe a patient responsibility fee. If we do not receive payment for the amount due on your statement within 14 days, we will run the credit card on file for the full amount owed.

Your account becomes delinquent if not paid within 30 days after the date of the original statement. The unpaid balance will be subject to a finance charge of 1.5% (18% APR) or $35, whichever is greater. Further delinquency will be subject to collections with additional finance fees and your care will be transferred to another office.

Upon registration, a staff member will collect your credit card information when the first appointment is scheduled.
Please sign to confirm that you understand and agree to the Credit Card on File office policy. I authorize Friendly Hills Pediatrics to charge my credit card for balances on my child's account. I understand that my information will be saved to file for future transactions on my account.*

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Consent to Treat Minor

Only for patients less than 18 years old
I, First Name*   Last Name*   , parent or legal guardian of the patient(s) listed above, hereby give consent to Friendly Hills Pediatrics to perform any radiology or lab testing, examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care as deemed advisable by a licensed physician, nurse practitioner or physician assistant, as well as any assistant on the staff of Friendly Hills
I understand that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required.
This consent is given to any and all such diagnoses, treatments and hospital care which a licensed physician at Friendly Hills Pediatrics recommends.
This authorization will remain in effect until revoked in writing by the parent or legal guardian.

Signature*

Date*
ASSIGNMENT OF BENEFITS
All professional services rendered are charged to the patient and are due at the time of service, unless insurance coverage is verified and Friendly Hills Pediatrics is a participating provider. Necessary forms will be completed to file for insurance carrier payments.

Assignment of Benefits

I hereby assign all medical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including private insurance and any other health/medical plan, to issue payment check(s) directly to Friendly Hills Pediatrics for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by

Authorization to Release Information

I hereby authorize Friendly Hills Pediatrics to: (1) release any information necessary to insurance carriers regarding myself and/or my dependent's illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims. This order will remain in effect until revoked by me in writing.

I have requested medical services from Friendly Hills Pediatrics on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges (copay, coinsurance and/or deductible) incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.

I have read and understand all the above statements and agree to uphold the terms and conditions of the above policies of Friendly Hills Pediatrics.
Parent/Legal Guardian's Signature*

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Parent/Legal Guardian's Name*

First NameLast Name
Date*

MonthDayYear
Date
How did you hear about our office?
Welcome to Friendly Hills Pediatrics!

We are looking forward to being your pediatric medical home.
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FRIENDLY HILLS PEDIATRICS

NEW PATIENT REGISTRATION

MEDICAL INSURANCE INFORMATION

PARENT INFORMATION

Parent/Legal Guardian #1

Parent/Legal Guardian #2

EMERGENCY CONTACTS

PREFERRED PHARMACY

Member Dues

Transfer of Care and Medical Records

COPAYMENTS & DEDUCTIBLES

NO SHOW FEES

DIVORCED PARENTS AND CUSTODIAL ARRANGEMENTS

CREDIT CARD ON FILE

Consent to Treat Minor

ASSIGNMENT OF BENEFITS