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Gastroenterology Hepatology Nutrition
1901 NEWPORT BLVD., STE. 235, COSTA MESA, CA. 92627
Ph 949 646-6224 Fax 949 646-6222
Patient Name: __________________________________ Sex: M F
Address: ______________________________________ Date of Birth _________
City: ____________________________ State: ______ Zip: _______ Ph # ( ) ____________
****************************************************************************
Father’s Name: __________________________ DOB: _______Social Security # ___________
Father’s Employer: _____________________ Work Phone: _____________ Cell#: __________
Work Address: _________________________ _________________ __________
Street City Zip
Drivers License # ___________________ State ______ Exp. Dt. _________
*****************************************************************************
Mother’s Name: _________________________ DOB: _______ Social Security# ____________
Mother’s Employer: ____________________ Work Phone: ______________ Cell#: _________
Work Address: __________________________ ________________ ___________
Street City Zip
Drivers License # ___________________ State_______ Exp Dt. __________
******************************************************************************
Medical Insurance:
Primary ________________________ ID# ____________ Group # ____________
Subscriber ___________________________________ Date of Birth ____________
HMO _____ PPO ____
Secondary ______________________ ID# _____________ Group ____________
Subscriber _____________________________________ Date of Birth ____________
HMO _____ PPO ____
****************************************************************************** Emergency Contact (other than parent) Name _________________ Ph# ________Relationship _________
Who may we thank for referring you to our office? __________________ Ph # _____________
__________________________________ _____________________________
Today’s Date Patient or Guardian Signature
Anjuli Kumar, M.D. Mini Mehra, M.D. Barry Steinmetz, M.D. Robert Tran, M.D. Malinda Lin, M.D.
PEDIATRIC GASTROENTEROLOGY PATIENT HISTORY FORM Please help us get to know you and your child better by providing us with the following information.
Pt name: _________________________________________ DOB: ____/____/_______
Mother/Guardian
Occupation Does your child have any siblings?
Father/Guardian
Occupation Who does the patient live with?
Primary Care Physician/Pediatrician
Phone: Fax:
Other doctors involved in your care:
Review of Systems: Please help us understand your child’s health history by answering the following questions.
Has your child ever been diagnosed with any of the following? If YES, please check any that apply and explain
in the space provided.
SYSTEM YES NO SYSTEM YES NO SYSTEM YES NO SYSTEM YES NO
Birth History Heart Endocrine/ Metabolic Skin
Birth Wt: High blood
pressure Diabetes Rash
Normal Low blood
pressure Thyroid
disease Lesions
Premature Irregular
heartbeat Brain/Neurological Dietary
Caesarean Chest pain Seizures Restricted diet
Ventilator Lungs Weakness Weight loss
Intestinal/ GI issues
Asthma Headaches Obesity
Diarrhea Pneumonia Migraines Food allergies
Constipation Chronic cough Blind/deaf Psychosocial
Rectal
bleeding Hoarseness Cerebral
palsy Depression
Heartburn Kidney/ Urinary Mental
retardation Anxiety
Trouble
swallowing Kidney
disease Blood/ Bleeding Alcoholism
Nausea Frequent urine
infection Hemophiliac Substance
Abuse
Vomiting Pain with
urination Easy bruising Other
Abdominal
pain Bedwetting Sickle Cell
Jaundice
Liver disease
Please continue on the next page
Page 1
PEDIATRIC GASTROENTEROLOGY PATIENT HISTORY FORM-page 2
Past Medical History: Please answer the following questions about your child’s past medical problems.
Please explain any YES answers in detailed description in the box provided
Have he/she ever had any surgery
or been hospitalized? __No
__Yes, Please explain
Have he/she had any problems
with anesthesia? __No __Yes,
please explain:
Surgeries: (Please also provide
dates)
Hospitalizations other than surgery:
Is he/she currently taking any
medications or vitamins?
Please list medications:
1.
2.
3.
4.
Drug Allergies:
Family History: Please indicate if you or your spouse, your parents, family members, and/or children ever had any
significant medical conditions:
Age Medical problems
Mother
Father
Siblings
1.
2.
Grandparents:
1.
2.
Social History: Please answer the following about your child’s home environment
Grade in school: Hobbies: Extracurricular activities:
Tobacco use in the house?
__No __Yes Alcohol use?
__No __Yes Pets:
Please feel free to provide your GI specialist with any additional information that you think is important in allowing
them to get to know you and your child better.
_____________________________________ _____________________________ ________________
Person completing this form Relationship to patient Date
_____________________________________ ________________
Reviewed by provider Date
PEDIACTRIC GASTROENTEROLOGY ASSOCIATES
OF SOUTHERN CALIFORNIA
Overview of our Financial Responsibilities PGASC’s Responsibility- To post charges and payments accurately. To process claims and statements to the
responsible party based on the best information available to us. This includes direct insurance billing and patient
billing for remaining balances. To provide accurate financial counsel to parents who contact our billing office.
Parent/Patient Responsibility- To assure that PGASC is provided with the most current insurance information
known. To provide timely payment to PGASC for all balances known to be the responsibility of the parent/patient.
To be responsible for all copays, deductibles and coinsurance at the time of service.
General Payment Policies:
Insurance Coverage
We ask that you bring your child’s insurance card with you each time you visit our office. When you check in at our front desk at
each visit, we will ask to see and verify your child’s insurance card for our records. Making a copy of your insurance card does not
confirm that PGASC providers are contracted with your insurance plan. It is your responsibility to know whether PGASC is a
provider for your insurance company. If you do not have your insurance card with you at your child’s visit, you may be asked to pay
at the time of service and/or sign a waiver of responsibility. Once the current information is furnished to us, and the insurance
company makes payment, PGASC will issue you a reimbursement payment.
Initial ______
Changes in Insurance Coverage
If there is any change in insurance, it is your responsibility to bring it to our attention immediately. Delays in communicating these
changes may result in the balance being uncollectible from the insurance company and the responsibility for payment will fall upon
the parent/patient.
Initial _____
HMO Insurance
PGASC is contracted with many HMO networks. It is your responsibility to have the approved referral/ authorization at the time
of your appointment.
Initial _____
Cash Patients
Payment in full is required at the time of service. Any exceptions to this policy must be arranged with management prior to the date of
your visit.
Initial _____
Collection Accounts
PGASC exhausts all efforts to research and resolve aged accounts prior to sending to an outside agency. In the event that an account is
sent to a collection agency, an additional 30% fee will incur in addition to 1.8% monthly interest. These are separate charges from
services rendered by our group. You will also be responsible for all attorney fees that incur.
Initial ______
Missed Appointments
Our policy is to call and confirm all appointments the day before. In the event that you are unable to make your appointment, we
require a 24-hour cancellation notice. If you are running late, we always appreciate a phone call to the office Please note that if you
are significantly late, we will try our very best to still see you. There are times that we might need to reschedule your appointment so
that our providers can spend an adequate amount of time with your child and other patients.
Initial _____
Billing Inquiries
Thank you for taking the time to understand our financial policies. PGASC’s goal is to provide quality care! If
you have any questions regarding your plan benefits or limitations, please contact your insurance carrier
directly. If you have any questions or concerns about the financial aspects of your relationship with PGASC,
please feel free to contact our business department at (949) 698-8215.
Authorization/Consent Patient _______________________________ Date of Birth __________ Parent/Guardian ______________________________
Print Name Signature
Yes ___ No ___ I hereby authorize PGASC to provide medical treatment to the patient listed on this form.
Yes ___ No ___ I hereby authorize third parties to pay directly to PGASC any insurance benefits due for services
rendered on behalf of the named patient.
Yes ___ No ___ I authorize PGASC to furnish my insurance company any medical information necessary to process our
Insurance claims.
To Our Patients,
To ensure you and your child fully benefit from the medical care and treatment planned by your
Physician, we ask for your cooperation by following our policy for arriving on time to appointments and
keeping schedule appointments.
Here is a summary of our policy requirements:
1. Arriving on time for scheduled appointments
Patients who arrive more than 15 minutes late may have their appointment cancelled and
rescheduled.
2. Cancelling Appointments
It is important for you and your child’s medical care to keep all scheduled appointments
We require a call to cancel more than 24 hours before a scheduled appointments, this
allows us to schedule another patient waiting for an appointment.
Calling less than 24 hours before a scheduled appointment is considered a missed
appointment.
Not arriving for an appointment is considered a missed appointment.
I have read and understand that when I make an appointment and do not call within 24 hours to
cancel, another patient could have that appointment and I will be charged $30.
Date:_____________________ Name of Patient (print):______________________________________
Signature:________________________________ Relationship to patient:_____________________
PEDIATRIC GASTROENTEROLOGY
ASSOCIATES OF SOUTHERN CALIFORNIA
Anjuli Kumar, M.D. Mini Mehra, M.D. Barry Steinmetz, M.D. Robert Tran, M.D.
COSTA MESA—1901 Newport Blvd, Suite 235 Costa Mesa, CA 92627 Tel: 949-646-6224 Fax: 949-646-6222
LONG BEACH –- 1760 Termino Ave, Suite 300 Long Beach, CA 90804 Tel: 562-933-3009 Fax: 562-933-8557
TORRANCE –- 3640 Lomita Blvd, Suite 102 Torrance, CA 90505 Tel: 310-378-1716 Fax: 562-933-6743
www.SoCalKidsGI.com
IMPORTANT NOTICE
Pediatric Gastroenterology Associates of Southern California makes every effort to refer you to
“in network” laboratories and imaging facilities that are members of most health plans.
However due to changes in the healthcare industry, some insurance carriers have chosen to
“contract” with specific laboratories and imaging facilities for their members.
If your insurance carrier chooses to contract with a specific facility, it is your responsibility to
notify us so that we can refer you to those contracted providers. With more than 100 plans for
which we are providers, it is not possible for us to know the details of each of these plans as we
are not always notified by your insurance carrier.
PLEASE BE AWARE THAT IT IS YOUR RESPONSIBILITY
TO KNOW THE DETAILS OF YOUR HEALTH PLAN
If you are in doubt as to whether a procedure, laboratory test, or imaging request is covered
and where it must be performed, please contact your insurance carrier.
Our office is not responsible for any out of pocket expenses resulting from the use of a non-
contracted facility or for tests/procedures not covered under your benefit plan.
Thank you for your understanding.
Signature: Date:___________________
Relationship to patient:_____________________________________________
Print Patient Name:________________________________________________
Gastroenterology Hepatology Nutrition