New Patient Packet 18 and older

Welcome to Alzein Pediatrics!
PATIENT Information
Today's Date:*

MonthDayYear
Patient's Birth Date:*

MonthDayYear
Patient's Name:*

FirstMILast
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender:
Who can we thank for your referral?*
Emergency Contact:*
Relationship to Patient:*
Emergency Contact Phone Number:*

Area CodePhone Number
Email (for access to your patient portal):*

Help us provide better care by answering these questions.
Languages Spoken at Home:*

ArabicEnglishIndian DialectPolishSpanishOther
INSURANCE INFORMATION
Please remember that copays are due at time of service. Thank you!
Primary Insurance Company Name:*
Cardholder's Name:*
Cardholder's Phone Number:*

Area CodePhone Number
Insurance ID#:*
Group#:*

Pharmacy Information
Please identify your preferred pharmacy. When you need prescription medication, we'll call the prescription into this pharmacy.
Pharmacy Name:*
Pharmacy Phone Number*

Area CodePhone Number
I authorize my treatment by a Provider employed by Alzein Pediatrics. I authorize the release of any information concerning my healthcare, advice, and treatment provided for the purpose of evaluation and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to the Provider, realizing I am responsible to pay non-covered services. I am also aware of the payment and fee policies of Alzein Pediatrics.
Signature of Patient*
Date:*

MonthDayYear
Date

MEDICAL HISTORY
Pre-Maturity:*
Apnea:*
Congenital Problems:*
Heart Problems:*
Cancer:*
Asthma:*
Arthritis:*
Chemical Dependency:*
Convulsion/Epilepsy*
Heart Disease*
Hemophilia (Bleeding)*
Diabetes*
High Blood Pressure:*
Kidney Disease:*
Mental Disorder:*
Migraines:*
Sickle Cell:*
Tuberculosis:*
Other:

Family History
Please specify family members using the following initials of whom had the following illnesses.

M- Mother F- Father B- Brother S- Sister PG-Paternal Grandfather PGM -Paternal Grandmother MG - Maternal Grandfather MGM - Maternal Grandmother
Allergies:*
Family Member:
Anemia:*
Family Member:
Arthritis:*
Family Member:
Autoimmune Disease:*
Family Member:
Asthma/Emphysema*
Family Member:
Birth Defects:*
Family Member:
Blood Disease*
Family Member:
Bone/Muscle Disease*
Family Member:
Cancer *
Family Member:
If yes, specify type of Cancer:
Cystic Fibrosis:*
Family Member:
Drug/Alcohol Abuse:*
Family Member:
Diabetes:*
Family Member:
Eye/Ear Disorder:*
Family Member:
Heart Disease:*
Family Member:
Heart Attack < 50:*
Family Member:
High Blood Pressure:*
Family Member:
Infections:*
Family Member:
Kidney/Liver Disease:*
Family Member:
Learning Problems:*
Family Member:
Mental Illness/Retardation:*
Family Member:
Metabolic/Genetic Disorder:*
Family Member:
Nerve Disorder (Epilepsy):*
Family Member:
Rheumatic Fever:*
Family Member:
Sickle Cell Trait/Disease:*
Family Member:
Skin Disease:*
Family Member:
Tuberculosis or Exposure:*
Family Member:
Thyroid Disease:*
Family Member:

HIPAA Acknowledgement of Notice of Privacy Practices
Alzein Pediatric Associates is required by law to maintain the privacy of and provide patients and their guardians with access to the Notice of our legal duties and privacy practices with respect to protected health information.
Name of Patient:*

First NameMILast Name
Patient's DOB:*

MonthDayYear
Date
I hereby acknowledge that I have reviewed the Hipaa Notice of Privacy document and understand that I may obtain a copy for my records upon request.
Signature of Patient*
Today's Date*

MonthDayYear
Cell Phone of Patient*

Area CodePhone Number
Home Phone of Patient*

Area CodePhone Number
Please let us know which number you would like us to call regarding your medical information. We will leave a message at this number if we do not reach you.*

Home PhoneCell Phone

Alzein Pediatrics Financial Policy
We are committed to providing you with the best possible care. If you have medical insurance, we wish to help you receive your maximum allowable benefits. To achieve this, we need your understanding of and assistance with our financial and payment policy.
Insurance: For your convenience, we will submit your claim and assist you in any way we reasonably can to get your claim paid. Insurance plans vary considerably and we cannot predict or guarantee what part of our services will or will not be covered. It is your responsibility to know your individual policy and to verify all benefits and coverage information prior to having services rendered. Your insurance policy is a contract between you and your insurance company.
Insurance Initials:*
Proof of Insurance: Proof of insurance must be shown at check-in at every visit. Without proof of insurance, you will be charged for the visit in full.
Proof Of Insurance Initials:*
Change of Insurance/Change of Address: Please notify the office as soon as possible of all insurance and address changes. If the guarantor does not notify the office within 15 days of any changes the guarantor is responsible for all charges not paid because of change in insurance coverage.
Change of Insurance/Change of Address Initials:*
Newborns: Most commercial insurance companies allow only 30 days to add your newborn to your plan. Please do so as soon as possible. All newborn bills will be held and sent to the insurance company once it can be verified that the newborn has coverage. By 2-months of age, all babies without proof of insurance will be expected to pay in full for their 2-month well visit and all visits since birth.
Newborns Initials:*
Self-pay: We do everything we can to mitigate the expense of anyone who is uninsured. Alzein Pediatrics provides a discount for self-pay patients. Payment is expected in full at the time of service for all charges.
Self-pay Initials:*
Co-Payments: We’re contractually obliged to collect, and you’re responsible to pay, your co-payment at the time of your visit. Please have your co-payment ready at check-in.
Co-Payments Initials:*
Deductibles & Coinsurance: Depending on your insurance policy, a deductible or coinsurance may be required at the time of service. Once the co-insurance amount has been established, the amount due at each visit will be the coinsurance percentage of the charges incurred, plus any deductible not yet met for the year.
Deductibles & Coinsurance Initials:*
Outstanding Balances: Any amount not covered by the insured/patient’s insurance is due within 30 days of the time of service. Balances on account must be paid prior to receiving additional services. Accounts will be turned over to a collection agency if past due 60 days or more. The patient family will be responsible for all collection costs involved with the collection of this account including court cost, reasonable attorney fees and all other expenses incurred with collection if there is a default on any unpaid balance. Should you have extraordinary financial pressure, we will assist you with a payment plan, agreed to in writing with our billing department prior to services being rendered.
Outstanding Balances Initials:*
Credit Card on File: Alzein Pediatrics is committed to making our billing process as simple and easy as possible. We require that all patients provide a credit card on file with our office. If a credit card is not available, we require a $200.00 retainer fee that will be applied towards any patient responsibility as determined by your insurance. Your card number will be saved in a secure PCI compliant site separate from the electronic medical recp. Credit cards on file can be used to pay copays and other charges at the time of the visit. The stored credit card would be used for payments toward patient responsibility, which is determined by your insurance company, unless the amount due is paid in full within 14 days of the statement.
Credit Card on File Initials:*
Coordination of Benefits: Responsible parties must respond to a request for information from the insurance within 10 business days. A failure to respond to a request for COB information from the insurance will result in all charges becoming patient responsibility.
Coordination of Benefits Initials:*
Cancellations: Our office charges a $25.00 no show fee for missed well/routine appointments. If you need to cancel your well/routine appointment, please contact us at least 48 hours in advance. This charge is not covered by your insurance and is the responsibility of the parent/legal guardian.
Cancellations Initials:*
Divorce: In the case of divorce or separation, the parent authorizing treatment for child/children will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent's responsibility to collect from the other parent.
Divorce Initials:*
Transfer of Records: Should you wish to transfer care to another physician, you will need to complete the authorization to release records form, which can be obtained from any of our clinic locations. This form needs to be completed in its entirety for us to process the request. All balances should be paid before records are transferred.
Transfer of Records Initials:*
The doctors at Alzein Pediatrics contract with most insurance plans. However, it is my responsibility to understand the benefits provided in my insurance plan. I am responsible for insurance copayments at the time of my visit, and I am also responsible for any outstanding balance once my insurance claim has been processed. I authorize payment of medical benefits directly from my insurance carrier to the treating physician for services provided.
Today's Date:*

MonthDayYear
Date
Patient Name:
DOB:

MonthDayYear
Should be Empty:

Welcome to Alzein Pediatrics!

PATIENT Information

INSURANCE INFORMATION

Pharmacy Information

MEDICAL HISTORY

Family History

HIPAA Acknowledgement of Notice of Privacy Practices

Alzein Pediatrics Financial Policy