• Patient and Family Information

    • Patient Info 
    • Patient's Birthdate*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Father 
    • Father's Date of Birth
       / /
      2 digit month, 2 digit day, 4 digit year
    • Format: (000) 000-0000.
    • Preferred Contact Method
    • Race of Patient
    • Ethnicity of Patient
    • Mother 
    • Mother's Date of Birth
       / /
      2 digit month, 2 digit day, 4 digit year
    • Format: (000) 000-0000.
    • Preferred Contact Method
    • Parents Marital Status 
    • Custody (skip if both parents have custody) 

    • We must have information for ALL plans, including copies of all ID cards, divorce decrees, and court orders.

    • Medical Insurance 
    • Date of Birth*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Additional Medical Insurance (if applicable) 
    • Date of Birth*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Additional Medical Insurance (if applicable) 
    • Date of Birth*
       / /
      2 digit month, 2 digit day, 4 digit year
    • Stepfather 
    • Stepfather's Date of Birth
       / /
      2 digit month, 2 digit day, 4 digit year
    • Stepmother 
    • Stepmother's Date of Birth
       / /
      2 digit month, 2 digit day, 4 digit year
    • Foster / Guardian / Other 
    • Other Contact Date of Birth
       / /
      2 digit month, 2 digit day, 4 digit year
    • Format: (000) 000-0000.
    • Preferred Contact Method
    • Siblings (if applicable) 

    • We are able to link charts and contact information for families with multiple children. Please list the siblings you would like associated with this patient.

    • Siblings
    • Completed By 

  • Acknowledgement

  • You are hereby notified pursuant to Michigan Law that as a patient of this practice your child may be tested for the presence of HIV or an HIV antibody without your consent if any health professional or other health facility employee sustains a percutaneous membrane open wound exposure to your child's blood or other body fluids. This test is permitted by Michigan Law and is for the protection of your child as well as the protection of the physicians and employees of Muskegon Pediatrics.

  • Patient's Birthdate
     / /
    2 digit month, 2 digit day, 4 digit year

  • Consent for Care in Absence of Parent

  • I, the parent/guardian named below, give permission for these Authorized Persons to bring my child/children, the patients named below, to Muskegon Pediatrics when I am unable to attend.

  • Patient's Birthdate
     / /
    2 digit month, 2 digit day, 4 digit year
  • Authorized Persons

  • Authorization to Share Information with Caregivers

    Complete this form to give Muskegon Pediatrics permission to share information about your children with authorized caregivers.

  • I, the parent/guardian named below, authorize the release and/or sharing of information about the Patient named below, with the following persons or entities listed below ("Authorized Caregivers").

  • Patient's Birthdate*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Authorized Caregivers

  • Financial Policy

  • Carequality Consent

  • Muskegon Pediatrics participates with the national Carequality registry. This registry allows hospitals and physicians across the country to exchange information regarding your health, such as current medications, most recent weight, height, blood pressure, and allergies. This exchange of information allows your child to receive better and informed care if he/she would need to visit an emergency room or see another physician.

    If you would NOT like to have this information available, please provide this in writing to Muskegon Pediatrics. 

    I acknowledge that I was given this information.

  • Muskegon Pediatrics No-Show Policy

  • Muskegon Pediatrics understands that unexpected things happen which could prevent patients from keeping their appointment with us. With that in mind, we expect parent/guardian/patient to notify our office as soon as they know they cannot keep a scheduled appointment. In the event that they fail to notify us within 2 hours of their appointment (except in circumstances out of your control) they will be assessed a “no-show” appointment. Three “no-shows” per family per 12-month period will result in the family being discharged from our practice.

     

    I acknowledge I was given this information.

  • Care Management Consent

    Care Management Consent

    Please review the information below and provide your consent for Care Management Services at Muskegon Pediatrics.

  • Care Management Services Consent

    Your provider and care team have identified that you may benefit from Care Management Services. These services are offered to help you better manage your health needs and achieve your health goals.

    Care Management Services May Include:

    • Assistance coordinating care among healthcare providers and community resources
    • Support managing health conditions and medications
    • Education to help you achieve your health goals
    • Assistance identifying barriers that may affect your health and well-being


    What Can I Expect?

    • A Care Manager will work with you to develop health goals and a care plan
    • The Care Manager may contact you by phone, telehealth, patient portal, mail, or in person.
    • The frequency of contact will be based on your individual needs
    • Participation is voluntary

    Billing Information
    Information regarding Care Management Services may be submitted to your health insurance plan as part of your participation in these services. If you have questions regarding your health plan benefits or coverage, please contact your insurance carrier. For questions about this process, please connect with your Care Manager.

    Your Rights

    • Participation in Care Management Services is voluntary
    • You have the right to ask questions about Care Management Services
    • You may decline or stop participating at any time
    • Your access to your provider or medical care will not be affected by your participation

    Consent
    I have received information about Care Management Services, including the services offered, what I can expect as a participant, billing-related information, and my right to decline or discontinue participation at any time. Participation is voluntary, and I may decline or end Care Management Services at any time.

  • Do you consent to participate in Care Management Services?*
  • Patient's Birthdate*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date signed
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date signed (patient)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: