Tender Care Pediatrics PC

Tender Care Pediatrics PC

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New Patient Registration Form

Today’s Date: _____________

Patient’s Name: ________________ _______ ____________ Pharmacy: ________________________

First Middle Last (Name and Location)

Date of Birth: ______________ Gender: M/F Ethnicity: Non-Hispanic/Hispanic or Latino/Declined

(MM/DD/YYYY) (Circle one)

Race: African American/ Alaskan or American Indian/ Caucasian/ Asian/ Hawaiian or Pacific Island/

Other/Declined (Circle one)

Patients Primary Address: Email: ____________________________________

Street & Apt #: ______________________________________________

City: _____________________________ State: _____ Zip: __________

Primary Phone: ( ) - : (cell / landline) ok to text Y/N MOM’s OR DAD’s

(Circle as applicable)

Secondary Phone: ( ) - : (cell / landline) ok to text Y/N MOM’s OR DAD’s

(Circle as applicable)

Mother Or Primary Care Giver Information: State Relationship: _______________

First Name: _________________________ Last Name:________________ DOB:_____________

SSN: - - Maiden Name: _________________

IF THE ADDRESS AND PHONE #S OF THE PRIMARY CARE GIVER ARE DIFFERENT FROM THE PATIENT,

PLEASE FILL BELOW:

Street & Apt #: ____________________________ City: ________________ State: _____ Zip: ______

Primary Phone: ( ) - : (cell / landline) ok to text Y/N (Circle as applicable)

Secondary Phone: ( ) - : (cell / landline) ok to text Y/N (Circle as applicable)

Father Or Secondary Care Giver Information: State Relationship: _______________

First Name: _________________________ Last Name:________________ DOB:_____________

SSN: - - Maiden Name: _________________

IF THE ADDRESS AND PHONE #S OF THE SECONDARY CARE GIVER ARE DIFFERENT FROM THE PATIENT,

PLEASE FILL BELOW:

Street & Apt #: ____________________________ City: ________________ State: _____ Zip: ______

Primary Phone: ( ) - : (cell / landline) ok to text Y/N (Circle as applicable)

Secondary Phone: ( ) - : (cell / landline) ok to text Y/N (Circle as applicable)


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Insurance Information:

Primary Insurance Company: _________________________________ Copay: _______

Insurance ID#: ___________________________ Group#: _________________

Policy Holder’s Name: _________________________________ Relationship: _______________

DOB:_____________ SSN: - -______

Please list any siblings that share the above-mentioned information:

1. First Name: _________________ Last Name: _________________ DB:___________




Please list any siblings With Different Demographics/Parental/Insurance

Information, please list below:





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Tender Care Pediatrics 2322 New Road, Northfield, NJ 08225

Phone: 609-641-0200

Fax: 609-641-1304

Consent for Treatment:

I, the undersigned, hereby authorize Tender Care Pediatrics Physicians and fheir authorized designates to perform lab test, administer immunizations and treatment as is necessary. I also certify that no guarantee or assurance has been made to the results that may be obtained.

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that my amount authorized to be paid directly to this office will- be credited to my account upon receipt. I permit this office to endorse remittances for the conveyance of credit to my account. However, I clearly understand and agree that all services rendefed to my children, spouse or self or charged directly to me and that I am personally responsible for payment.

Request for Payment of Benefits to Provider of Care:

I authorize my Insurance Company/Insurance Administrator to pay by check, and for it to be mailed directly to: Tender Care Pediatrics P.C., 2322 New Road, Northfield, NJ 08225 the expense benefits allowable and otherwi�� payable to me under my current policy, as payment towards the total charges for professional services rendered to my child/ward. I have agreed to pay, in a current manner, any balance of said applicable charges. I agree that this office be given power of attorney to endorse/sign my name on any and all drafts for payment of my bill.

Express Prior consent To Contact by Cell Phone:

In order for Tender Care Pediatrics to service your account or to collect monies you may owe, I agree Tender Care Pediatrics and/or authorized agents of Tender Care Pediatrics may contact me by telephone at any telephone number associated with your account, including mobil telephone numbers, which could result in charges to me. I also agree to be contacted via text messages or emails. Methods of contact may include using prerecored/artifici;ll voice messages and/or use of automatic dialing deives, as appropriate.

Consent for Treatment for Minor: r, the undersigned, hereby authorize Tender Care Pediatrics Physicians and whomever they may designate as her assistant(s) to perform lab test, administer immunizations and treatment as she deems necessary to my ( ),

·

- * :f1arent or Guardian's Signature: ___________________________________________

Pate: _____________________

Office Financial Polley

Here at Tender Care Pediatrics, we are doing .everything possible to hold.down the cost of medical care. You, the parent, can help a great deal by eliminating the need for us to charge and/or bill you for any reason. The following is an explanation of our Financial Polley. Please be sure to read the entire passage.

If you are a recipient of Medicaid or any of the.-HMO products such as Horizon NJ Health, United Community Plan and Amerigroup, you must adhere to the policies of the Medicaid Program. The Medicaid Program and the HMO products DO NOT cover any charges due to administrative fees. This includes any fees that are incurred from missed/late cancellation or rescheduling of appointments, print out of medical records and/or forms.

Fees and Insurance Coverage

All patient payments will be collected before any services ar� rendered. This includes, but is not limited to co-pays, patient balances related to administrative fees resulting from missed appointments, medical records and/or forms. Failure to pay your copay will result in an addi,lonal fee of $10 added to the balance. There is a $30 service charge for any returned checks.

/ .

During your child's annual well visit a vision screening will be performed and could result in a small fee applied by your insurance· compa.ny. If you refuse to have the screening performed, and require forms to be.filled out either at the time of service or in the future, we .... wlll indicate on any forms that the vision screening was declined and it will become your responsibility to obtain your current results from your eye doctor or return to our office, where a copay may apply, to have the vision screening done. In addition, if you are here for a preventative care visit and receive any non-preventative care services such as prescriptions or counseling for newly diagnosed illnesses or previously diagnosed chronic conditions a separate charge and/or copay, deductible or co-insurance may apply to the visit eyen If It was primarily a well child visit.

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Some appoint.ments may require additional services including but'not limited to wart treatments, hearing screens, strep tests and urine cultures to be performed at the time of the appointment and may result in additional fees aside from the office visit copay.

Medical Records

Any request for medical records REQUIRE a signed ·medical release form stating the authorization of release from Tender Care Pediatrics to either a parent or the current physician's office. There is a $10 administrative fee for each requested record.

Missed Appointments

Any missed appointment, cancellation/rescheduling same day of appointments will result in a $50 administrative fee per appointment. Three (3) or more appointments per family may result in a discharge from the practice. .,.

have read the above office financial policy for Tender Care Pediatrics and I agree to the terms listed above.

/ Signature: _________________________ Patient Name:__________________________ DOB:______________

Date:___________

Protected Health Information (PHI)/ HIPAA

� Patient Name (Print):______________________ Date, ______________________

Due to recent implemented Federal Regulations the following public notice by Tender Care Pediatrics PC is effective as of November 1, 2011.

The Tender Care Pediatrics PC is required to:

1. · Maintain the privacy of your health information.2. Provide you with this notice as to what our legal duties and privacy practices·are with respect to

information we collect aAndrews, Siennand maintain about you.

3. Abide by the terms of this practice.

4. Notify you if we are unable to agree to a requested restriction, and accommodate any reasonablerequest you may have to communicate health alternative means or alternative locations.

5. We will not use or disclose your health information without your authorization, except asdescribed in this notice.

6. We will use and disclose your PHI in order to bill and collect payment for the services and itemsyou may have received from us. For example, we will contact your insurer to certify that you areeligible for benefits and we may provide your insurer with details regarding your treatment todetermine if your insurer will cover, or pay for, your treatment.

WE ARE PERMI'ITED TO USE, AND MAY BE REQUIRED, TO DISCLOSE YOUR PHI UNDER SPECIAL CIRCUSTANCES:

I. Disclose Required By Law: Our practice �1 use and disclose your PHI when we are requiredto do so by federal, state, or local law, including health oversight activities, court oradministrative orders or similar le(al proceedings.

2. Public Health Risk: Our practice may disclose your PHI to public health authorities who areauthorized to collect information for such purposes as maintaining vital records, preventing orcontrolling disease, injury, or disability; or notifying a person regarding potential exposure to acommunicable disease.

3. Serious Threats to Health of Safety: Our practice may disclose your PHI when necessary toreduce or prevent a serious threat to your health and safety or the health and safety of anotherindividual or the public.

4. Deceased Patients: Our practice may release PHI to a medical examiner or coroner to identifya deceased individual or to identify-the cause of death. If necessary, we also may releaseinformation in order for funeral directors to perform their jobs.

5. Organ Donor: Our practice may release PHI to a medical facility for tissue procurement oftransplantation, including organ donation banks, as necessary to facilitate organ or tissuedonation and transplantation if you are an organ donor.

6. Work�r's Compenaatlon: Our practice may release your PHI for workers' compensation andsimilar programs.

Our practice may contact you or your authorized representatives (see authorization form attached) to

Tend·er Care Pediatrics PC

2322 New Road Northfield NJ082251440

Phone 609-641-0200


**Complete and return to Receptionist**

ACKNOWLEDGEMENT

I acknowledge that I have received the Notice of Privacy Practices from Tender Care Pediatrics PC and understand that if I have questions regarding this Notice I may contact the office at 2322 New Road, NJ 082251440 609-641-0200.

Indicated below are names of any Person(s) to whom I would like Tender Care Pediatrics PC to allow disclosure of Individually Identifiable Health Information (IIHI). (Please, specify the type of informati6n that may be disclosed, such as lab test, appointment information, prescription information, etc. You may indicate "All" if appropriate).

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Patient Name :-______________________________________

Patient Signature :____________________________________

TENDER CARE PEDIATRICS PC

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEAL TH

INFORMATION

With my consent, Tender Care Pediatrics may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to Tender Care Pediatrics's Notice of Privacy Practices for a more complete description of such uses and disclosures. I have the right to review the Notice of Brivacy Practices prior to signing this consent. Tender Care Pediatrics reserves the right to revise its Notice of Privacy,.Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Tender Care

Pediatrics Privacy Officer at 2322 New Road, Northfield, NJ 08225 With my consent, Tender Care Pediatrics may call my home or other designated location and

leave a message on voice mail or in person in reference to any items that assist the practice in

canying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others.

With my consent, Tender Care Pediatrics may mail to my home or other designated location any

items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.

With my consent, Tender Care Pediatrics may e-mail to my appointment reminder cards and

patient statements. I have the right to request that Tender Care Pediatrics restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am

consenting to Tender Care Pediatrics's use and disclosure of my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made

disclosures in reliance upon my prior consent. If I do not sign this consent, Tender Care

Pediatrics may decline to provide treatment to me.

Signature of Patient or Legal Guardian: ________________________________

Patient Name: __________________________________

/ /

TENDER�CARE PEDIATRICS PC 2322 New Road, Northfield, NJ 08225

Padma Mandalapu MD, FAAP Phone: (609) 641 - 0200 Fax: (609) 641 - 1304

1 11 the event or porentol/guardlnn absence I choose·to grnnt perrnlssJon to the·followlng pcoplu to bring my child/children .to Tender c;ore Pediatric&, I give permission to have vocclnes l.ldmlnlstered, complete phyalcnl exam& perrormed and ·any testing that may needto l.,e clone In U,e office t� dlngn�se my chlld/c�lldren. I nlso grnnt these people parmlsslon lo pick up prescriptions ror-cont_rtjl_lad sub,t�nc:es and any paperwork that l may need ror my chllcl/chlldren. Any faa5 that.yn!!tnccrue (or these services are my resp onsibility as longc1s I t1111 llsted as the _gunrd_lan at tha time o( service. I understand that this document Is fol' no other establishment other;lhnn Tender Care Pediatrics and permission does not extend beyond this office.

Ni.1 Ille of Chllcl • _.__ ____________ DOB· __ .,__---'..__ __ _

M,H111:1 of Child- -------------'---- DOB·--------

l'lume or Clllld- ------------- DOB-______ _

l'lume of Chlld- ---'-------'------ DOD-______ ___._

1,1a111e of Chllcl- -----.----------- DOB· _______ _

Permission grunted to: 1._··-'·------......... -----�--

2 ...... --. -------------

4·--------------

s. ____ / __ _.__�-�---

- ' - - .

Parent/Guardian Signature: __________________________________________ Date: _____________

Print Name: _______________________________ Circle relationship (Mother / Father / Guardian

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Tender Care Pediatrics PC