New Family Registration Packet

New Family Registration

Essex Pediatrics • 89 Main Street, Essex Junction, VT 05452 • (802) 879-6556
Instructions

Complete this form once for each family or household. It contains the following sections:
1. Patients
2. Release of Medical Records
3. Insurance
4. Family Demographics
5. Family Medical History
6. Policies and Procedures
7. Authorization for Other Caregivers
You will need your insurance card(s) and the subscriber's photo ID.

Patients

List the name and date of birth for each child in your family who is a patient.
How many children in the family are patients?*
Patient 1 Name*
Patient 1 Date of Birth*

MonthDayYear
Date
Patient 2 Name*
Patient 2 Date of Birth*

MonthDayYear
Date
Patient 3 Name*
Patient 3 Date of Birth*

MonthDayYear
Date
Patient 4 Name*
Patient 4 Date of Birth*

MonthDayYear
Date
Patient 5 Name*
Patient 5 Date of Birth*

MonthDayYear
Date
Patient 6 Name*
Patient 6 Date of Birth*

MonthDayYear
Date
How did you hear about Essex Pediatrics?*

Release of Medical Records
I am releasing medical records*

FROM another provider TO Essex PediatricsI have no records to release at this time
Reason for transferring:*
Physican Providing Records

Essex Pediatrics
89 Main Street
Essex Junction, VT 05452

Phone: (802) 879-6556
Fax: (802) 872-8021
Releasing Records To
Physician and/or Practice Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
I authorize the following to be released via fax/email/mail:*

All records of care between the Start and End dates noted aboveOther
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.

Insurance
Primary Insurance
Do you have primary insurance?*

YesNo
Primary Insurance Provider*
ID Number*
Group Number*
Subscriber's Name*
Subscriber's Date of Birth*

MonthDayYear
Date
To expedite your benefits confirmation, please upload a copy of the front and back of your insurance card. You can use your mobile phone to take these photos.
Front of Insurance Card*

Cancelof
Back of Insurance Card*

Cancelof
Secondary Insurance
Do you have secondary insurance?*

YesNo
Secondary Insurance Provider*
ID Number*
Group Number*
Copay*
Subscriber's Name*
Subscriber's Date of Birth*

MonthDayYear
Date
Start Date*

MonthDayYear
Date
To expedite your benefits confirmation, please upload a copy of the front and back of your insurance card. You can use your mobile phone to take these photos.
Front of Insurance Card*

Cancelof
Back of Insurance Card*

Cancelof
Medicaid
Have any of the patients listed above ever been on Medicaid? If so, list their name with the start and end dates:
Insurance Authorization and Assignment (Please Read and Sign)

I attest that the information I have given here is correct and true to the best of my knowledge. I hereby assign benefits to be paid directly to the doctor, and authorize him/her to furnish information regarding my visits to my insurance carrier. I understand that I am responsible for my entire bill unless this form is complete.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Family Demographics
Please list all other individuals living in the child’s home, who are not patients.
How many other individuals live in the child's home?*
Do not include any of the patients listed on the first page of this form.
Name 1*
Date of Birth*

MonthDayYear
Date
Relationship to Child*
Name 2*
Date of Birth*

MonthDayYear
Date
Relationship to Child*
Name 3*
Date of Birth*

MonthDayYear
Date
Relationship to Child*
Name 4*
Date of Birth*

MonthDayYear
Date
Relationship to Child*
Name 5*
Date of Birth*

MonthDayYear
Date
Relationship to Child*
Name 6*
Date of Birth*

MonthDayYear
Date
Relationship to Child*
Which languages are spoken regularly in the home?*
English
Are there pets in the home? If so, what kinds?
Are there guns in the home?*

Yes, lockedYes, unlockedNo
Is there exposure to tobacco or marijuana smoke or vapor?*

YesNo
What are the parents' occupations?*
Does your family have dietary preferences or restrictions? If so, provide details.

Policies and Procedures
Thank you for choosing Essex Pediatrics as your child’s health care provider. The following is a copy of our practice policies and procedures. Patient care is not permitted without the written consent of receipt and acknowledgement of the understanding of this policy.
Consent to Examine and Treat a Minor

I do hereby consent and authorize Essex Pediatrics and/or such associates, assistants or designees, to examine and treat my minor child(ren).

I affirm that I have the legal right to consent to this. This consent is binding until specifically revoked by myself or another person who has the right to sign or revoke this form.

I give the providers at Essex Pediatrics permission to treat my child in my absence in case of emergency or when accompanied by a designated representative.
Initials*
Patient Privacy

Essex Pediatrics providers and staff are governed by and comply with the federal Health Insurance Portability and Accountability Act (HIPAA). We are required to abide by the terms of our office Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at the time. A copy of our current HIPAA statement is available upon request. Patients age 18 and older are required to sign a waiver authorizing parental access to their account. Parents of patients over the age of 18 will not be permitted to access any medical or billing information without written consent of patient.
Initials*
Missed Appointments

Cancellations are required 24 hours prior to any well visit appointment and two hours prior to any sick visit via phone call to the practice. Essex Pediatrics reserves the right to refuse the rescheduling of missed double or triple sibling appointments. Multiple no-shows, per family, within a twelve-month period may result in dismissal from the practice.
Initials*
Late Arrivals

Appointment arrivals 15 minutes or greater than the scheduled appointment time may result in the need to reschedule the appointment.
Initials*
Records Requests

Should you wish to obtain a copy of your medical records, you must complete the authorization to release records form, which can be completed on our website. This form needs to be completed in its entirety. Records will be mailed to the assigned account holder or available for pick up at the office within 5 business days of the request and receipt of the signed records release and payment of $10.
Initials*
Referrals

Some insurances may require a referral to be completed by our office in order to see a specialist. If your insurance requires a referral, it is your responsibility to notify our practice no later than 7 days from the date of your appointment.
Initials*
Divorce and Custody

In the case of divorce or separation, the parent authorizing treatment for the child/children, i.e., the parent or authorized adult present for the appointment will be the person responsible for the subsequent charges. Should the divorce decree designate a particular parent as payor for all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the responsible party and not the responsibility of Essex Pediatrics. If there are legal documents regarding medical decision making that our practice should be aware of, it is your responsibility to provide that documentation to Essex Pediatrics.
Initials*
Payments

Payment, in full is due at time of service. This includes applicable co-insurance, co-payments, and payments for services not covered or denied by the insurance company. Essex Pediatrics accepts cash, personal check, debit cards, Visa, Mastercard, Discover, and American Express.
Initials*
Self-Pay Accounts

If you do not have insurance, please come prepared to pay for your visit in full upon check-out. A price list of services is available upon request. We offer a 20% discount for all self-pay services paid in full on the day of the visit.
Initials*
Missed Co-Pays

Essex Pediatrics is required by our insurance contracts to collect all co-pays at the time of service. Failure to collect co-pays puts the responsible party and Essex Pediatrics in default of the insurance contract. A $10 service fee will be charged in addition to your co-payment, if the co-payment is not paid by the end of that business day.
Initials*
Outstanding Balances

If you have a personal balance on your account, a monthly statement will be sent. Unless authorized in writing, payment is due upon receipt of statement or within 28 calendar days. A rebilling fee of $7 will be added to your account each month until the balance is paid or the account has been sent to collections.
Initials*
Payment Plans

Essex Pediatrics understands that full payment may not be possible in certain circumstances. As a courtesy, Essex Pediatrics may offer the assigned account holder a payment plan. Payment plans are approved on a case-by-case basis and may be discussed with our management team. Patients with a payment plan must be in full compliance with all conditions of the agreement at time of visit. Failure to make scheduled payments on the payment plan, or not paying off a balance in full, may result in your account being turned over to a collection agency and your family being dismissed from the practice.
Initials*
Collection Accounts

If your account is submitted to a collection agency, all associated fees are the responsibility of the assigned account holder, including a collection fee equal to 50% of the collection balance. The assigned account holder will receive written notification by way of a dismissal letter and given 30 calendar days to find a new health care provider. If your account is sent to collection and then paid in full, the assigned account holder may request the practice reinstate the account.
Initials*
Returned Checks

A $30 fee will be charged for any checks returned for insufficient funds.
Initials*
After Hours/Holiday Care

There is a $40 fee for visits that occur after 5:00pm (EST) daily, on weekend days and federal holidays. If that fee is not covered by your insurance carrier, the assigned account holder is financially responsible for the charges.
Initials*
Insurance

We accept most insurances including most Medicaid plans. Please call the office to confirm acceptance of your coverage.

Please bring your insurance card to the first visit of the year. A scanned copy of the assigned account holder’s current insurance card is required to be kept on file. Please present newly issued insurance cards upon check-in at the next scheduled visit.

If you have an HMO insurance plan, please assign one of the physicians in our practice as your child’s primary care physician (PCP) prior to your visit. If we cannot confirm that one of our providers is listed as your child’s PCP, we will ask that the appointment be rescheduled.

During a preventative care visit, if we address additional problems, topics, or concerns, or we address any ongoing chronic medical conditions, we must also document and claim these problems to your insurance company. Depending on your insurance, these additional problems will often be subject to co-pays and deductibles, so you may receive an additional bill for this service. Please see our website for more information.
Initials*
Change of Insurance/Change of Account Information

Please notify the office as soon as possible of any and all account changes, including co-pay amounts, insurance updates, and change of mailing address. If the account holder does not notify the office within 15 calendar days of these changes, the assigned account holder becomes responsible for any and all charges.
Initials*
Billing Inquiries

Questions about a bill should be directed to our billing department at (802) 879-6556.
Initials*
Family Dismissal

Essex Pediatrics reserves the right to terminate the patient/practice relationship at any time if violation of the aforementioned policies occurs.
Initials*
Review and consent of this policy is required prior to services rendered.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date

Authorization for Other Caregivers
I want to authorize additional caregivers to give consent to treatment for the patient(s).*

YesNo
Authorization for Caregivers Other Than Parent or Guardian

The people listed below are designated as our agent to give consent (verbal or written) to surgical or medical treatment by any licensed physician or provider at Essex Pediatrics for my minor child, and to receive relevant protected health information. Such consent may include but is not limited to, administration of necessary anesthetics, medical treatment, test, X-ray examinations, transfusions, injections, immunizations or drugs and the performing of whatever procedures may be deemed necessary or advisable.

It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide the authority to consent thereto as our said agent and the above-named child’s attending physician, in the exercise of their best judgement, may deem advisable. This authorization shall remain effective unless revoked in writing by the undersigned.
Caregiver 1 Name*

First NameLast Name
Relationship to Patient*
Caregiver 2 Name

First NameLast Name
Relationship to Patient
Caregiver 3 Name

First NameLast Name
Relationship to Patient
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

New Family Registration

Instructions

Patients

Release of Medical Records

Physican Providing Records

Releasing Records To

Insurance

Primary Insurance

Secondary Insurance

Medicaid

Insurance Authorization and Assignment (Please Read and Sign)

Family Demographics

Family Medical History

Policies and Procedures

Consent to Examine and Treat a Minor

Patient Privacy

Missed Appointments

Late Arrivals

Records Requests

Referrals

Divorce and Custody

Payments

Self-Pay Accounts

Missed Co-Pays

Outstanding Balances

Payment Plans

Collection Accounts

Returned Checks

After Hours/Holiday Care

Insurance

Change of Insurance/Change of Account Information

Billing Inquiries

Family Dismissal

Authorization for Other Caregivers

Authorization for Caregivers Other Than Parent or Guardian