PLACE LABEL HERE PEDIATRICIAN PREFERENCE SHEET I understand that: 1. I am responsible for any bills I receive from the doctor who cares for my baby in the hospital. 2. Not all doctors accept all insurances or self-pay patients. 3. Some doctors may not accept new patients. Please choose one of the following: Dr. ________________________ will care for my baby. I do not have a pediatrician for my baby and want Gwinnett Medical Center to get me a doctor. *Groups with an asterisk do not take Medicaid patients (no exceptions, even if baby has a sibling on Medicaid and sibling is currently being seen by that pediatrician/group). ______________________________ _______________________ Signature of Patient Date Pediatricians Who Attend Newborns at GWP All About Kids Pediatrics * Braselton Pediatrics Buford Pediatrics CARE Pediatrics Covenant Family Medicine* Crescent Pediatrics Delta Pediatrics Eastside Pediatrics Family Care Clinic Gwinnett Neonatology Gwinnett Pediatrics * Assign to Gwinnett Neonatology Hamilton Mill Pediatrics Ivy League Pediatrics Kaiser Pediatrics* Kid's Choice Pediatrics Lawrenceville Pediatrics * Lilburn Pediatrics Longstreet Clinic Mason Children’s Clinic (Kid’s Clinic) Medilag Pediatrics, P.C. Medlock Pediatrics Millcreek Pediatric Associates Pediatric Associates L’ville* Perisseia Physicians Shah Pediatrics South Gwinnett Pediatrics St. Joseph’s Pediatrics * Stay Well Pediatrics Sugarloaf Pediatrics Suwanee Pediatrics United Pediatrics Verras Pediatrics Jill Overcash, MD Marc-Yriane Borieux, MD Nirmala S. Bharadwaj, MD Noelle Ruddock-Solomon, MD Rene Latoni, MD William Moneit, MD Emmanuel Mordi, MD Muhammad Ali, MD Renso Fornasini, MD Leslie Leigh, MD Shannon Cole, MD Bridget Duffy, MD Hal Herd, MD Joanne Jackson, MD Suzanne Molock, MD David Thomson, MD Nneka C. Unachukwu, MD Andrew Adam, MD Candace Kay Greene, MD Venkateswara Dikkala, MD Lise Baudean, MD Charlotte Khan, MD Vijay Arora, MD Laura Putnam, MD Howard Ellis, MD Divya Joshi, MD Babatunde I. Onasanya, MD Maria Batlle, MD Mabel Njoku, MD Anna Lawson, MD David Kunz, MD May Hawawini, MD Joyce Lovett, MD Effie Dolores, MD Neha Nailesh Soni, MD Susamma Mathew, MD Bolaji Odusina, MD Tayaba Fatema, MD Athanasios Verras, MD Henry Moon, MD Danni Suskin, MD Yvette Quisling, MD Lisa Roberts, MD Susan Smiley, MD Sharon Steele, MD George Stickney, MD Riad Alsayed Amhad, MD Ashley Stolle, MD Anna Tanner, MD Keyana Washington, MD Monique Welsh-Evans, MD Tracy Lynn Jimerson, MD Jaime Pham, MD Thomas J. Steimer, MD Tandua O. Washington, MD James Lin, MD Melissa Magill, MD Vicki Morgan, MD Michael Tim, MD Sarvpreet Kaur, MD Anita Khichi, MD Guna Sekar, MD Jean Song, MD Pat Tyagi, MD Kathryn Benson, MD Savita Rajgiri, MD Christian Messick, MD Anuradha Sheth, MD Taru Shah, MD Deepa Mony, MD THIS SHEET IS FOR INFORMATION ONLY AND NOT A PART OF THE PERMANENT RECORD. *2-28707* Page 1 of 2 FORM 2-28707 REVISED 12/13/2012 PLACE LABEL HERE HOJA DE PREFERENCIA DE LOS PEDIATRAS PEDIATRICIAN PREFERENCE SHEET Entiendo que: 1. soy responsable por cualquier factura que reciba del médico que atiende a mi bebé en el hospital; 2. no todos los médicos aceptan todas las compañías de seguros o a pacientes que realizan sus propios pagos; 3. algunos médicos pueden no aceptar pacientes nuevos. Elija uno de los siguientes: El Dr. ________________________ atenderá a mi bebé. No tengo pediatra para mi bebé y quiero que Gwinnett Medical Center me consiga un médico. *Los grupos con un asterisco no ven pacientes con Medicaid. (No excepciones, aún si el bebé tiene un hermano(a) con Medicaid, que está siendo atendido por este grupo ó pediatra actualmente) ______________________________ Firma del paciente _______________________ Fecha Pediatricians Who Attend Newborns at GWP All About Kids Pediatrics * Braselton Pediatrics Buford Pediatrics CARE Pediatrics Covenant Family Medicine* Crescent Pediatrics Delta Pediatrics Eastside Pediatrics Family Care Clinic Gwinnett Neonatology Gwinnett Pediatrics * Jill Overcash, MD Marc Yriane Borieux, MD Nirmala S. Bharadwaj, MD Noelle Ruddock-Solomon, MD Rene Latoni, MD Henry Moon, MD William Moneit, MD Emmanuel Mordi, MD Muhammad Ali, MD Renso Fornasini Leslie Leigh, MD Danni Suskin, MD Riad Alsayed Amhad, MD Shannon Cole, MD Yvette Quisling, MD Ashley Stolle, MD Bridget Duffy, MD Lisa Roberts, MD Anna Tanner, MD Assign to Gwinnett Hal Herd, MD Susan Smiley, MD Keyana Washington, MD Neonatology Joanne Jackson, MD Sharon Steele, MD Monique Welsh-Evans, MD Suzanne Molock, MD George Stickney, MD Hamilton Mill Pediatrics David Thomson, MD Ivy League Pediatrics NNeka C. Unachukwu, MD Kaiser Pediatrics Andrew Adam, MD Tracy Lynn Jimerson, MD Thomas J. Steimer, MD Candace Kay Greene, MD Jaime Pham, MD Tandua O. Washington, MD Kid’s Choice Pediatrics Venkateswara Dikkala, MD Lawrenceville Pediatrics * Lise Baudean, MD James Lin, MD Vicki Morgan, MD Charlotte Khan, MD Melissa Magill, MD Michael Tim, MD Lilburn Pediatrics Vijay Arora, MD Sarvpreet Kaur, MD Longstreet Clinic Laura Putnam, MD Mason Children’s Clinic Howard Ellis, MD Anita Khichi, MD Jean Song, MD (Kid’s Clinic) Divya Joshi, MD Guna Sekar, MD Pat Tyagi, MD Medilag Pediatrics, P.C. Babatunde I. Onasanya, MD Medlock Pediatrics Maria Batlle, MD Kathryn Benson, MD Millcreek Pediatric Associates Mabel Njoku, MD Savita Rajgiri, MD Pediatric Associates L’ville * Anna Lawson, MD Christian Messick, MD Anuradha Sheth, MD Perisseia Physicians David Kunz, MD Shah Pediatrics May Hawawini, MD Taru Shah, MD South Gwinnett Pediatrics Joyce Lovett, MD St. Joseph’s Pediatrics * Effie Dolores, MD Stay Well Pediatrics Neha Nailesh Soni, MD Sugarloaf Pediatrics Susamma Mathew, MD Deepa Mony, MD Suwanee Pediatrics Bolaji Odusina, MD United Pediatrics Tayaba Fatema, MD Verras Pediatrics Athanasios Verras, MD THIS SHEET IS FOR INFORMATION ONLY AND NOT A PART OF THE PERMANENT RECORD. FORM 2-28707 REVISED 12/13/2012 Page 2 of 2