• New Patient Packet

    Pediatrics
  • Personal Information

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  • Financial Responsible Party Information

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  • Insurance Information

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  • Emergency Contact

  • Reason for Visit

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  • Allergies

  • Current Medications

  • Preferred Pharmacy Information

  • Statement of Patient Financial Responsibility

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  • Mercy Grace Private Practice appreciates the confidence you have shown in choosing us to provide for your health care needs. The service you have elected to participate in implies a financial responsibility on your part. The responsibility obligates you to ensure payment in full of our fees. As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. However, you are ultimately responsible for payment of your bill.
     
    You are responsible for payment of any deductible and co-payments/co-insurance as determined by your contract with your insurance carrier. We expect these payments at time of service. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amounts not covered by your insurer. If your insurance denies any part of your claim, or if you or your physician elects to continue past your approved period, you will be responsible for your balance in full.
     
    Should your account fall into a default status due to non-payment, your balance may be eligible for collections. Collections balances should be taken care of immediately to avoid disruption in services. Any account in collections status may be eligible for discharge. Arrangements for any balance should be made immediately.

  • DISCLAIMER: By signing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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  • Co-Pay Policy

    Some health insurance carriers require the patient to pay a co-pay for services rendered. It is expected and appreciated at the time the service is rendered for the patient at EACH VISIT. Mercy Grace Private Practice does NOT bill for co-pays. Thank you for your cooperation in this manner.
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  • Authorization to Bill/Pay

    I HEREBY AUTHORIZE MERCY GRACE PRIVATE PRACTICE TO AND ITS AFFILIATES TO RELEASE ANY INFORMATION REQUIRED IN THE COURSE OF MY EXAMINATION OR TREATMENT WHICH INCLUDE HIV, COMMUNICABLE DISEASE OR DRUG ABUSE INFORMATION. I ALSO HEREBY AUTHORIZE PAYMENT DIRECTLY TO THE BUSINESS OF MERCY GRACE PRIVATE PRACTICE AND ITS AFFILIATES FOR THE SURGICAL AND/OR MEDICAL BENEFITS, IF ANY, OTHERWISE PAYABLE TO ME FOR THE SERVICES RENDERED. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES NOT COVERED BY MY INSURANCE. FURTHER, I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED IN THE COLLECTION OF MY ACCOUNT(S) AND WILL PAY ALL FEES INVOLVED SHOULD MY ACCOUNT(S) BE PLACED WITH A COLLECTIONS SERVICE.DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
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  • Self-Pay

    I agree to pay Mercy Grace Private Practice the full and entire amount for the treatment provided to me.
  • Consent for Treatment and Authorization to Release Information

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  • I hereby authorize Mercy Grace Private Practice through its appropriate personnel, to perform or have performed upon me, or the above-named patient, appropriate assessment and treatment procedures.
     
    I further authorize Mercy Grace Private Practice and its affiliates, to release appropriate agencies, any information acquired in the course of my, or the above named patient’s, examination and treatment.
     
    DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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  • Cancellation / No Show Policy

    We understand there may be times when you miss an appointment due to emergencies or obligations to work or family. However, we urge you to call 24 hours prior to your appointment to cancel. Please initial the following:
  • Our office will notify you in writing, via mail, if you are discharged from care.
     
    I have read and understand the above information and I agree to the terms described:
     
    DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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  • HIPPA NOTICE OF PRIVACY PRACTICES

    I hereby acknowledge that I have been presented with Mercy Grace Private Practice’s HIPAA Notice of Privacy Practices. My signature below is indicative of my acknowledgment and understanding. I am aware that I can obtain a copy of this in the office or on www.mgppaz.com. All of my questions have been answered accordingly.DISCLAIMER: By signing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
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  • Release of Information

  • I hereby authorize MGPP to release or discuss any and all information pertaining to myself or my child with       

  • I authorize MGPP to contact me at HOME WORK CELL
     
    DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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