Patient Acknowledgement of Privacy Practices
Patient Name:______________________________ Date of Birth________________
I understand that the patient’s health information is private and confidential. I understand that Stepping Stones Pediatrics works
very hard to protect the patient’s privacy and preserve the confidentiality of the patient’s personal health information.
I understand that Stepping Stones Pediatrics may use and disclose the patient’s personal health information to help provide health
care to the patient, to handle billing and payment, and to take care of other health care operations. In general, there will be no
other uses and disclosures of this information unless I permit it. I understand that sometimes the law may require the release of this
information without my permission. These situations are very unusual. One example would be if a patient threatened to hurt
someone else.
Stepping Stones Pediatrics has a detailed document called the Notice of Privacy Practices. It contains more information about the
policies and practices protecting the patient’s privacy and is located in the waiting area. I understand that I have a right to read the
Notice before signing this Acknowledgement.
Stepping Stones Pediatrics may update this Acknowledgment and Notice of Privacy Practices. If I ask, Stepping Stones Pediatrics will
provide me with the most current Notice of Privacy Practices.
Within this Notice of Privacy Practices is contained a complete description of my privacy/confidentiality rights. These rights include,
but are not limited to, access to my medical records, restrictions on certain uses, receiving an accounting of disclosures as required
by law, and requesting communication be by specified methods.
Stepping Stones Pediatrics has established procedures that help to meet their obligations to patients. However, these procedures
may require other signatures, written acknowledgements and authorizations, which may result in administrative charges. I will
assist Stepping Stones Pediatrics by following these procedures if I choose to exercise any of my rights described in the Notice of
Privacy Practices.
My signature below indicates that I have been given the opportunity to review a current copy of Stepping Stones Pediatrics Notice of
Privacy Practices.
__________________________________________________
Patient or legally authorized individual signature
_____________________________
Date
____________________________________________________________________________________________
Relationship to patient if signed by anyone other than patient. (Parent, legal guardian, personal representative, ect.)
Patient Registration Form
PATIENT INFORMATION: (Please use full legal name, no nicknames).
Last Name:
First Name:
Middle
Initial:________
Date of Birth: ______/______/_______
Age: ____
Sex: ________
Social Security Number:
___________________
Primary Language: ________________________ Ethnicity: ______________________________ Race:
__________________________________
Address/City/State/Zip:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
__________________________
Best Contact Numbers:
____________________________________________________________________________________________________
Who lives at this household?
_______________________________________________________________________________________________
SIBLINGS:
Child 2:
Last Name:
First Name:
Date of Birth: ______/______/_______ Age: ____ Sex: ________
Social Security Number: ___________________
Child 3:
Last Name:
First Name:
Date of Birth: ______/______/_______ Age: ____ Sex: ________
Social Security Number: ___________________
Child 4:
Last Name:
First Name:
Date of Birth: ______/______/_______ Age: ____ Sex: ________
Social Security Number: ___________________
PARENT INFORMATION:
Parent 1:
Last Name:
First Name:
Date of Birth: ______/______/_______ Age: ____ Sex: ________
Social Security Number: ___________________
Does this Parent live with the child? __ Yes __ No Email Address:______________________________________
Work Number: ___________________________ Cell Phone Number ________________________________
Employer: ___________________________________ Occupation: __________________________________
Parent 2:
Last Name:
First Name:
Date of Birth: ______/______/_______ Age: ____ Sex: ________
Social Security Number: ___________________
Does this Parent live with the child? __ Yes __ No Email Address:_________________________________________
Work Number: ___________________________ Cell Phone Number ________________________________
Employer: ___________________________________ Occupation: __________________________________
If parents are divorced or separated please fill out this section:
Who has custody?
____________________________________________________________________________________________________
Are there any legal restrictions that would restrict the non-custodial parent from consenting to medical treatment for the child or
from obtaining information about the child’s medical treatment? If yes, please explain and provide any legal paperwork that
supports this restriction:
____________________________________________________________________________________________________________
EMERGENCY CONTACTS:
1.
Last Name:
First Name:
_______________
Phone Number _____________________________
Relationship:______________________________
2.
Last Name:
First Name:
Phone Number _____________________________
Relationship:_______________________________
PHARMACY INFORMATION
Pharmacy Name:_________________________________ Location:______________________ Phone Number:_________________
INSURANCE
GUARANTOR INFORMATION (List person or insured name responsible for bill – use full legal name, no nicknames).
Relationship of Guarantor to Patient: __ Self __ Spouse __ Parent __ Other:
Last Name:
First Name:
Middle
Initial:________
Date of Birth: ______/______/_______
Age: ____
Sex: ________
Social Security Number:
___________________
Address/City/State/Zip:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Contact Numbers:
_________________________________________________________________________________________________________
Employer’s Name and Address:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
PRIMARY INSURANCE (Please allow receptionist to photocopy your insurance ID cards)
Plan Name: _____________________________________________________ Insured’s Name:
___________________________________________
Insured’s Social Security Number: __________________________________ Insured’s Date of Birth:
____________________________________
Policy/ID#: _________________________________ Group Number: ______________________ Effective Date:
____________________________
Claims Address and Phone Number:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
SECONDARY INSURANCE
Plan Name: _____________________________________________________ Insured’s Name:
___________________________________________
Insured’s Social Security Number: __________________________________ Insured’s Date of Birth:
____________________________________
Policy/ID#: _____________________________ Group Number: _______________ Effective Date: _________________________
Claims Address and Phone Number:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
FINANCIAL POLICY
Thank you for choosing Stepping Stones Pediatrics. We are committed to providing outstanding patient care to children and
adolescents. We look forward to establishing a lasting relationship and partnership with you in caring for your child. Before we
provide medical services, we require that you review our financial policies and agree in writing to accept them.
USUAL AND CUSTOMARY RATES: We participate with most insurance plans. Your insurance coverage and benefits are a contract
between you and your insurance company. Not all insurance policies cover all services. It is your responsibility to check with your
insurance company to determine covered benefits. You are responsible for payment regardless of the insurance company’s
determination of usual and customary rates. You are responsible for any balance remaining after your insurance carrier has
processed the claim.
If you do not have your insurance card, one of our physicians’ names is not on the card, and/or we cannot verify coverage, you may
be asked to sign a waiver and leave full payment at time of visit. We do allow newborns to be seen until their two month physical
while their insurance is pending. After the two month visit, if your insurance is stilling pending, the patient will be considered self-pay
and will be responsible for any pending charges and for the office visit for that day.
SELF PAY: If you do not have insurance, you will be considered a “self-pay” patient. “Self-pay” patients will be given an estimate of
what will be due and required to pay for all services at the time they are rendered. This may not include labs or other ancillary
services. You will receive a bill for any unpaid charges.
INSURANCE COLLECTION: It is your responsibility to ensure that we have the most current copy of your insurance card, demographic
and contact information. If your insurance is not verified at time of service, you will be responsible for payment at time of service.
CO-PAYMENTS: Payment is expected at time of service. Failure to produce payment at check-in may result in your appointment
being rescheduled. Certain services (i.e. ear piercing) are not covered by your insurance. For any questions regarding
services/treatments, we encourage you to contact our Practice Manager and/r your insurance carrier to review costs. Failure to pay
at the time of service will result in a $15.00 service fee. As a convenience, we accept cash, personal checks, Visa, MasterCard and
discovered. We do not accept post-dated checks. There is a $25.00 fee for returned checks.
DEDUCTIBLES AND FEES: Insurance deductibles are due at the time of service rendered. Failure to produce payment at check-in may
result in your appointment being reschedule and will incur a $15.00 fee. Patients with yearly deductibles will be required to pay
$50.00 at time of service. Failure to pay $50.00 at time of service will incur a $15.00 service fee and full payment for any future
appointments. We will require a copy of your health savings account debit/credit card or a personal debit/credit card to remain on
file in our office. Your card will be charged and a receipt generated once your insurance company sends us your explanation of
benefits for the claim. If there has been an overpayment, we will issue you a refund check. Depending on your insurance, weekend
and after hour appointments may incur an extra $50.00 fee; you would need to check with your insurance to see if this added
charge is covered.
OUT OF NETWORK/NON-PARTICIPATING INSURANCE CARRIERS: If your insurance carrier considers us “out of network” or does not
participate with us, you are responsible for payment in full at the time of service. We will gladly provide any proof of visit/receipts,
ect;
DIVORCE DECREES: In the case of services provided for minors, the individual who initiates services for the child will be responsible
for payment. This office is not a party to your divorce decree. We do not bill another individual or estranged spouse for payment.
Copayment is due at the time services are rendered. If the divorce decree requires the other parent to pay all or part of the
treatment, it is the authorizing parent’s responsibility to collect from the other parent. Stepping Stones Pediatrics will not act as a
mediator in collecting our payments.
NO SHOW/CANCELLATION POLICY: Missed appointments represent a cost to us, to you and to other patients who could have been
accommodated. Appointments missed or not cancelled at least 24 hours before the appointment will result in a $25.00 no show
fee. Missed appointments made the same day and not cancelled within 2 hours of the appointment will also be subject to a no
show fee for $25.00. Appointments can only be cancelled by calling during regular business hours.
FORM CHARGES: Please be mindful that completion of your child’s form require time. Forms that are to be completed within 5-7
business days will have a charge of $5.00. Forms that need to be completed within 3 days incur a $10.00 charge. Any form that
needs to be completed in less than 3 days or within the same day as drop off will incur a $20.00 charge.
PAST DUE PAYMENTS: Just as we make every effort to accommodate you when your child is in need of medical care, we expect you
will make every effort to pay your bill promptly. If you have a financial hardship, or if you are unable to pay your bill in its entirety,
please contact our office to discuss payment options. If your account become delinquent (past due 60 days) your account will be
subject to interest, rebilling fees, and collection costs. Should collection action become necessary, the responsible party agrees to
pay an additional 30% collection fee, and all legal fees of collection, with our without suit, including attorney fees and court cost. No
balance over $200.00 per family can be carried on a family account.
A service charge of $25.00 will be added for returned checks, re-filing of insurance due to incomplete or incorrect information given
at time of service, and for administrative fees associates with accounts turned over to collection agencies.
TRANSFER OF CARE: When relocating or transferring care to another provider, we will request and require you to close out any
balances due. For any records that need to be transferred out when you leave our practice, you will need to complete a Medical
Release Form in our office. Records are copied by Healthport and are subject o a $.75 per page fee. If there are any questions about
your bill or status of your records, call Healthport at 1-800-367-1500.
ADDITIONAL FINACIAL POLICIES:
-
-
Please be aware that it is not uncommon for the patient to receive a regular check up and an evaluation of an acute or
chronic illness. In these cases, your insurance company may be billed for a well child exam and an additional office
visit.
We will not verify coverage by telephone or internet when you present for a visit. It is the parent’s responsibility to
have this information available for whoever is present with the child for the visit.
I authorize Stepping Stones Pediatrics to release all requested information concerning my medical treatment to my insurance
carrier. I further authorize my insurance company to pay from the proceeds of benefits of any recovery or insurance payments in
my case, directly to the provider(s) of this office, for their professional services rendered.
Stepping Stones Pediatrics reserves the right to dismiss any patient from the practice who consistently fails to meet this policy or
who refuses to sign this agreement.
By signing below, I understand and agree to the terms of this office’s Financial Policy.
______________________________________________________________
Child’s Name
___________________________________
Child’s Date of Birth
______________________________________________________________
Parent or Legal Guardian
___________________________________
Today’s Date
ANNUAL HIPAA
This form must be updated each year to ensure accurate information.
Last Name: __________________________________ First Name: ______________________________ Middle Initial
____
Date of Birth: ______________________________ Email Address: _____________________________________________
Address/City/State/Zip Code:
_____________________________________________________________________________________________________
_
_____________________________________________________________________________________________________
_
In our efforts to comply with the Health Insurance Portability and Accountability Act (HIPAA), we need to be certain that we guard
your privacy according to your wishes when it comes to your family, friends and co-workers.
Please provide us with a phone number(s) that we or an automated services may leave messages regarding appointments:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
__________________________
Please provide us with the name(s) and phone number(s) that we may talk to regarding your appointments:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
__________________________
Please provide us with the name(s) and phone number(s) that we may talk to regarding your treatment and test results:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
__________________________
Please provide us with the name(s) and phone number(s) that we may talk to regarding your billing:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
__________________________
Please provide an email that we may communicate health information to you with:
____________________________________________________________________________________________________________
_____________
Please provide a cell phone number that we may text health information to you with:
____________________________________________________________________________________________________________
_____________
You must inform us in writing of any changes in your directives.
I acknowledge that all of the above is accurate.
__________________________________________ _____________________________________________
___________________
Signature
Printed Name
Date
I acknowledge that I have seen or been offered a copy of the Notice of Privacy Practices.
__________________________________________ _____________________________________________
___________________
Signature
Printed Name
Date
Effective Oct. 1, 2012
Private providers may no longer provide Vaccines for Children (VFC) immunizations to underinsured children.
Definition of UNDERINSURED:
The following children are considered uninsured if:
-
They have commercial (private) health insurance but the coverage does not include vaccines*
Their insurance covers only selected vaccines (in this scenario, only non-covered vaccines may be provided through
VFC)
Or their insurance caps vaccine coverage at a certain amount – once that coverage amount is reached, these children
are categorized as underinsured.
*NOTE: Children whose health insurance covers vaccinations are not eligible for VFC vaccines, even when a claim for the cost of the
vaccine and its administration would be denied for payment by the insurance carrier because the plan’s deductible had not been met
or because the insurance did not cover the total cost of the vaccine.
Under these circumstances there will be two choices:
-
A parent can take their child to the LHD (Local Health Department) where they can receive VFC vaccine; however, the
LHD is allowed to charge an administration fee.
The underinsured child can receive the vaccine here at Stepping Stones Pediatrics, however, you be charged for the
vaccine along with the administration charge of $35.00 for the first shot and then $17.00 for each additional shot.
The vaccine fees will be collect at the time of service.
___________________________________
Child’s Name
______________________
Child’s DOB
___________________________________
Parent or Guardian
______________________
Date