GRAHAM PEDIATRICS OF WOODSTOCK
105 Mirramont Lake Drive, Woodstock. Ga 30189
Phone 770 -485-9670, Fax 866-698-9350, www. grahampediatrics.com

 

PATIENT REGISTRATION FORM

Patient Information *

(If more than one child register here)

PARENT/GUARDIAN INFORMATION

INSURANCE INFORMATION

FINANCIAL/PRIVACY POLICIES (HIPPA)

 

By signing below, I authorize and acknowledge each of the following:

• I authorize Graham Pediatrics of Woodstock (GPOW) to evaluate and treat the above name(s).

• I authorize GPOW to use/release my medical information for treatment purposes to other physicians, specialists, health care providers etc. and billing information to insurance companies so that payments for charges can be processed and paid directly to GPOW. 

• I acknowledge that I am financially responsible for copays, deductibles and co-insurances and any other services that are not covered by my insurance plan or for any outstanding balances on patient’s account at the time of service. I will also be financially responsible for the visit at the time of service if I don’t show proof of an active insurance.

GRAHAM PEDIATRICS OF WOODSTOCK
105 Mirramont Lake Drive, Woodstock. Ga 30189
Phone 770-485-9670, Fax 866-698-9350, www. grahampediatrics.com

 

Financial Responsibility Form

Graham Pediatrics of Woodstock (GPOW) partners with you to take care of your child. We would like to take the time to clarify our expectations of your responsibilities, please read and sign, acknowledging your understanding of our financial policies.

For each visit please bring your:

• Current insurance card (without current insurance information there is no way for us to verify eligibility and file your claim/visit, so, when you don’t provide us with this important information, you will be considered as self-pay on the day of service). Please remember to bring a valid photo ID.
• Copays or Deductibles: Patients are responsible for insurance copays or deductibles at the time of service. We will collect payment from the attending parent/guardian.

Private Insurance (Newborns/Patients)

• Please provide our office with the policy holder information: name, date of birth, address, phone number, and a copy of the insurance card in order for us to verify eligibility at the time of service.
• Note: If you apply for a private insurance, please note that most private insurance plans give 30 days to activate coverage for your baby, please make sure that all your paperwork has been received by your insurer carrier, so that coverage will be in place before your baby’s 1st month checkup to avoid claims being denied by the insurance and you paying out of pocket for current and previous services.

Medicaid Insurance (Newborns/ Patients)

• If you apply to Medicaid and do not have a Medicaid ID number or card at the time of your visit, please bring “a printed copy of proof that you have applied” otherwise you will be financially responsible for the visit at the time of service. Also, as a courtesy we allow 6 weeks for your child to obtain a Medicaid ID number, after that time, you are financially responsible for present and previous visits.

Self-Pay

• If we are not in-network with your insurance or your child does not have insurance, you will be considered selfpaid and the balance must be paid in full at the time of visit.

Coinsurance: As a courtesy we bill co-insurance, after your insurance has processed your claim.

Coordination of benefits: If you have two health insurances, it is your responsibility for you to call each insurance and do “coordination of benefits” this means that each insurance knows that you have another insurance. Please make sure that we are in-network with both insurances, otherwise your claims will be denied, and you will be financially responsible for any balance generated from these denials.

Combined visits: If you are scheduled for a well child exam, and other health concerns are brought up that would typically require a sick visit, your insurance company may consider these two separate visits and generate a statement for your copay and other charges accordingly.

Billing/Payment

• Your insurance contract is between you and your insurance carrier not GPOW. You are financially responsible for all charges not paid by your insurance carrier, and you will be sent statements regarding your balance.
• Patients must know their insurance benefits and what type of visits, vaccines, well check, labs or other procedures are included and covered by their insurance.
• The parent/guardian whose names are listed in the Patient Registration Form are responsible for patient’s outstanding balances.
• We will send you several statements for outstanding balances. For balances that remain unpaid after 60 days, you’ll need to call the office and make the necessary financial arrangements. Failure to do so, will result in your account sent to a collection agency. We will require the collection agency balance to be paid via cash, debit or credit card prior to any future visits. You may be asked to be financially responsible for the visit at the time of the service and will be refunded any payments made by your insurance company. Any family whose account is forwarded to a collection agency may be dismissed from the practice.
• It is your responsibility to clear your balance upon your due date on your bill or if you have a visit before that, whichever comes first. We accept Visa, Master Card, American Express, Discover for your convenience.

By signing below, you agree to accept full financial responsibility as a patient who is receiving medical services, or as the responsible party for minor patients. Your signature verifies that you have read the above disclosure, understand your responsibilities, and agree to these terms.

Child Information *

GRAHAM PEDIATRICS OF WOODSTOCK
105 Mirramont Lake Drive, Woodstock. Ga 30189
Phone 770-485-9670, Fax 866-698-9350, www. grahampediatrics.com

 VACCINE POLICY

        We firmly believe in the effectiveness of vaccines to prevent life threatening illnesses and to save lives. We firmly believe based on all available literature, evidence, and current studies that vaccines, preservatives or a combination of the two do not cause autism or other developmental disabilities. Please be advised that by not vaccinating on the given schedule, you are putting your child at unnecessary risk for life-threating illnesses and disabilities, and even death. 

        Our expectation for new and existing patients is to vaccinate according to the given schedule by the Centers for Disease Control or the American Academy of Pediatrics including the MMR vaccine. If you do not plan on vaccinating according to this policy, we advise you to find another provider who shares your views. Furthermore, we do not offer alternative schedules as this puts your child at further unnecessary risk of infection.

        By signing this form, I agree to have my child fully vaccinated in a timely manner as scheduled by the Centers for Disease Control or the American Academy of Pediatrics. I understand that otherwise I have chosen for my child to NOT be a patient at this practice. 

Child Information *

CONSENT TO TREATMENT
 

I hereby authorize for my child(ren) to be medically evaluated and treated by the providers of Graham Pediatrics of Woodstock as well as staff and designees. I understand that treatments and services may include, but is not limited to: lab tests, vaccines, screening exams, diagnostic testing, and routine physicals.

Child Information *

This authorization will remain in effect until revoked in writing.

GRAHAM PEDIATRICS OF WOODSTOCK
105 Mirramont Lake Drive, Woodstock. Ga 30189
Phone 770-485-9670, Fax 866-698-9350, www. grahampediatrics.com

 

NON-PARENT CONSENT FORM

We require the consent of a parent/legal guardian to provide medical care for patients under the age of 18 and when a parent/legal guardian is not present. I authorize Graham Pediatrics of Woodstock (GPOW) and its personnel to deliver routine medical care to my child(ren) listed below, this includes but is not limited to consent for necessary medications, vaccinations, and procedures. I understand that I can revoke this authorization for any or all of these individuals at any time.

Children covered by this consent (list full names and date of birth)

Child Information *

I authorize the following individual(s) to bring in my children to their appointments:

APPOINTMENT POLICY

Our goal is to provide quality medical care in a timely manner and to serve your child’s medical needs. Graham Pediatrics of Woodstock prefers to work only by appointments to serve you better.

 

- For scheduled appointments: After 3 no shows/cancellations (less than 24 hours prior to your appointment), you have chosen to find another provider.

- For same-day appointments: After 3 no shows/cancellations (less than 2 hours prior to your appointment), you have chosen to find another provider.

 

-Rescheduled Appointments: After 5 consecutives short notice reschedule, you have chosen to find another provider

Please CALL our office:

• If you need an appointment for an additional child prior to your arrival.
• If you are late, we have a 15 minute grace period after your appointment time. Otherwise, we will have to reschedule your appointment.
• If you need to reschedule your appointment, please call us 24 hours prior to your appointment.

Our office makes reminder calls for your appointment. This is done as courtesy to you. It is your responsibility to confirm and to attend to your appointment as scheduled.        

I acknowledge that I have been given the opportunity to read the Notice of Privacy Practive Policy for Graham Pediatrics of Woodstock (GPOW)     and I can access it through the GPOW website under Forms & Insurances and Privacy Statement.