New Patient Enrollment (including health history)

New Patient Enrollment
Please Note:

This form will take approximately 10 minutes to complete.

Several consent and policy forms within the intake will require your E-Signature.

Please do not print these forms. Please fill them out online 24 hours before your visit. We are a Paperless Practice utilzing Electronic Health Records.

All information is Confidential.

In Case of Emergency
Emergency Contact:

First NameLast Name
Contact Number
Relationship

Family Members
Sibling Name/DOB
Sibling Name/DOB
Sibling Name/DOB
Sibling Name/DOB
Sibling Name/DOB

Insurance Information
Name of Primary Insurance Carrier*
Member Id No.blanks* Group No. blank*
Primary Insurance Carrier's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Secondary Insurance Carrier (if applicable)
Member Id No.blanks Group No. blank
Secondary Insurance Carrier's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby authorize Edmond Pediatrics to furnish information to insurance carriers concerning my child's illness and treatments and hereby assign to the doctor all payments for medical services rendered to my dependents or myself. I understand that I am responsible for any amount not covered by insurance. *

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Authorization for Treatment of Minor
By electronically submitting this consent, I authorize Edmond Pediatrics to give routine medical treatment and services to my child. This could include and is not limited to: medical evaluation, physical exam, routine immunizations and lab work. In my absence, I authorize the below named individuals to bring my child for care in my absence.
Name

First NameLast Name
Relation to Patient
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Relation to Patient
Phone Number
Please enter a valid phone number.
Signature of Patient or Guardian Indicating that they have read and agree to Authorization of Treatment of Minor*

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Edmond Pediatrics Vaccination Policy Agreement
I understand that I must vaccinate my child according to the schedule provided by Edmond Pediatrics. I understand that this is a private practice and the providers can choose to deny care to my child if I do not follow the scheduled recommended by Edmond Pediatrics and the American Academy of Pediatrics.

I understand that the first set of vaccines begin at the 2-month Well Child Check and I agree to abide by the schedule and vaccinate my child based on my provider's recommendations.
By e-signing this form, I am stating that I have read, understand and agree to abide by the vaccination policy of Edmond Pediatrics and failure to do so could result in a dismissal from the practice.*

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Edmond Pediatrics Photo Consent

Edmond Pediatrics staff may ask to take a photo(s) of your child during a visit to our clinic. We may use these photos on our social media platforms, website, ads, or within the clinic.
I...*

DO consent to the use of my childs photo as described above.DO NOT consent to the use of my childs photo as described above.
Signature*

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Patient Portal Enrollment
By submitting my email, I authorize Edmond Pediatrcs to enroll my family in the Patient Portal.
Parent/Guardian Email*
example@example.com

DLO Acknowledgement
It is the patients responsibility to know which lab, diagnostic facility, or specialist is in their insurance network. If the patient does not provide the staff of Edmond Pediatrics with the correct information, all labs will be sent to Diagnostic Laboratory of Oklahoma (DLO). Any additional charges due to being out of network will be the patients responsiblity.
Please indicate below, if you prefer that Edmond Pediatrics send any lab work to a different facility.
Name of Preferred Lab

Acknowledgment of Privacy Practices and Consent
A complete description of how your medical information will be used and disclosed by Edmond Pediatrics is in our NOTICE OF PRIVACY PRACTICES, which you should read before signing this agreement. A copy is available to you upon registration and is posted in Edmond Pediatrics facilities. The full notice is also available by following this link: Notice of Privacy Practices
By signing this agreement I acknowledge reciept of Edmond Pediatrics Notice of Privacy Practices and authorize the use and disclosure of my medical information as described in the Notice of Privacy Practices.
Responsible Party*

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Basis for refusal, if refused

Financial Policy

Thank you for choosing Edmond Pediatrics as your health care provider. We are dedicated to providing exceptional service and care to your and your family. All patients must complete our new patient information before seeing our providers. In addition to providing your insurance information, Edmond Pediatrics requires a copy of your current insurance card on file at all times. Please read your policy and be aware of your benefits and obligations; your clear understanding of our Financial Policy is important to our professional relationship.
ALL PAYMENT IS EXPECTED AT THE TIME OF SERVICE

Payment is required at the time services are rendered. Copayments are contractually set by the insurance companies based on the policy you and
your family have chosen, and we are contractually bound to collect them. The person bringing the patient to the clinic for their appointment is
responsible for paying the copayment and any outstanding balances on the account at the time of service unless previous arrangements have been
made. If you fail to pay your co-payment, you will be charged an administrative surcharge of $25.00 for processing the co-payment after your visit.

TYPES OF PAYMENT ACCEPTED

Edmond Pediatrcs accepts cash payments, Visa, Master Card, Discover, American Express and personal checks. However, for any returned checks, a $25.00
‘returned check fee’ will be applied.

Copays

Copayments are due at time of check-in when applicable. A $25.00 processing fee will be applied if the co-pay is not paid on the day of the service.

Credit Card on File

Edmond Pediatrics requires a credit card on file for all patients with commercial insurance. We reserve the right to run the card on file for patient's responsibilty remaining 60 days after date of service. Please see Credit Card policy for more information. Sign up today by following this link:

CREDIT CARD ON FILE SIGN UP FORM

Due to the high number of our patients on High Deductible Health Plans, the Credit Card on File will facilitate the billing process. If a balance is unpaid 120 days from service, we reserve the right to submit the account to Collections and charge applicable fees. Families are dismissed once sent to Collections.

Re-Billing Fee

For our patients who are non compliant with our Credit Card on File Policy, effective mid-March 2024 when a balance is greater than 60 days from the date of service, your account will be charged a $30.00 Re-Bill Fee for every monthly billing cycle that carries a balance greater than 60 days old.

Edmond PediatrIcs makes every effort to collect what is owed to us, including engaging the services of a professional collection agency for
unpaid patient balances. Therefore, if a balance goes unpaid for 120 days from the date of service, the account may be turned to a collection
agency. If the account is turned to a collection agency, the guarantor will be responsible for paying all collection and legal fees. Once an account
has been turned, the family will be dismissed for the practice.

SELF PAY

If you do not have insurance, you are considered to be self-pay. The guardian present will be responsible for paying all charges billed for the appointment. We will apply a 20% courtesy discount if you are able to pay in full. Guarantor could receive an additional bill after the service if the provider runs any lab tests on the patient. The lab tests will also receive a 20% discount. Payment is due in full at time of visit. If charges for any lab work is not taken at time of service, you will receive an itemized invoice.

INSURANCE

As a courtesy to our patients, Edmond Pediatrics will file all patient claims to the insurance company for reimbursement. The guarantor is
responsible for paying the copayment and any outstanding deductible/co-insurance charges at the time of service. Any charges not covered by
insurance will be billed to the guarantor and will be his/her responsibility to pay them. It is the policy holder’s responsibility to make sure that
claims are paid in a timely fashion. We are more than happy to work with you and your insurance company to resolve any issues if needed.

DIVORCED PARENTS

Edmond Pediatrics will not get involved in custodial, seperation, or financial disputes involving or relating to divorced parents for a minor child(ren) we provide services to. The parent who signs the initial financial policy and registration form for minor child(ren) will be the responsible party for payment on services rendered. Edmond Pediatrics does not mediate or participate in disagreements between parents. The legal/biological parent with authorization to obtain medical treatment at time of service is responsible for payment and medical decision making.

SoonerCare Patients

If the patient's SoonerCare is not fully active on the day of the service, we will do our best to contact you prior to the time of the appointment. Our providers can not treat your child until the SoonerCare is active and elgibible. We will work with you to re-schedule your child's appointment if the issue is not resolved at time of check-in.
I have read the Edmond Pediatrics financial policy, and I agree to the terms listed above*

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Late Arrival, Incorrect Location, & Missed Appointments Policies
Late Arrival

If you are an established patient and you arrive 15 minutes late or more to your appointment you will likely be asked to reschedule unless the physician’s schedule can still accommodate you. Priority will be given to the patients who arrive on time and you may have to be worked in between them. This may mean you will have a considerable wait. If this is not convenient for you, you may choose to reschedule. One or two late patients cause the entire daily schedule to fall behind. This is an inconvenience to everyone. We strive to see every patient as close to their appointment time as possible. Likewise if you are a new patient and you arrive at the scheduled appointment time and not early to complete your forms as instructed and it takes more than 15 minutes to complete the forms and the registration process, you may also be asked to reschedule.

Incorrect Location

The same terms will apply if you arrive late to the incorrect location. We will do our best to accommodate you at the location of arrival however if it is not possible we will ask you to reschedule. Accommodating patients on to a different provider’s schedule can result in a lengthy wait time.

Missed Appointments

A “No Show” charge of $25.00 will be billed when there is a failure to provide a 24-hour cancellation notice for a Well Child Visit or Sick Visit. This charge is not covered by insurance and you will be responsible for payment. Every attempt is made to provide reminder calls or text messages for appointments scheduled in advance; this is a courtesy only and has no effect on the financial obligation for missed appointments. After 3 misses without notification, our office does attempt to contact the account holder to discuss the office policy regarding missed appointments. If after the conversation, the patient continues to miss appointments without notification, unfortunately Edmond Pediatrics may have to terminate our patient/provider relationship in order to open up the appointment times to other patients.
I have read the Edmond Pediatrics Late Arrival, Incorrect Location, and Missed Appointment Policy and I agree to the terms listed above*

Clear

Medical Home Agreement

This Medical Home Agreement concept is an AGREEMENT between YOU and YOUR PROVIDER, to focus on meeting ALL of your healthcare needs
As a Medical Home Agreement Patient, your responsibility is the following:
1. Work with us, as your PCP, to meet all of your health care needs.
2. Communicate with us about all your healthcare concerns and goals.
3. Report any changes related to your health, treatments, medications, etc.
  - This includes use of all medications-prescription, over-the-counter, herbal, and street drugs
  - This also includes and medical equipment being used that has been ordered or reccomended for use.
4. Call us before going to the Emergency Room, unless it is life threatning.
5. Notify us after any Emergency Room, Urgent Care Clinic, or Hospital visit.
6. Schedule medical appointments in a timely manner, including follow-up appointments.
7. Keep appointments as scheduled with us and any appointments scheduled with a specialist.
8. If you cannot keep an appointment call before your appointment time to cancel or reschedule the appointment.
9. You may be dismessed from your PCP if you repeatedly miss appointments without notice or do not follow the responsibilities listed in the medical home agreement.
As your Medical Home Primary Care Provider (PCP), we agree to:
1. Honor your rights as a patient, and treat you with dignity and respect.
2. We will focus on listening to your concerns, educating you on your health care needs and preventative services.
3. Focus on treating you as a whole person: physically, mentally, and emotionally.
4. Focus on providing you with ongoing, quality, and safe medical care; including prevention of future health complications.
5. Work to schedule timely office appointments for your chronic and urgent healthcare needs.
6. Be available to you 24 hours a day, by office appointment, phone calls and/or other electronic communication.
7. Provide you with other healthcare resources when we are absent or unavailable.
8. Provide you with referrals to specialist as deemed medically necessary by your PCP.
9. Provide you with treatment, medications, equipment, and other resources deemed medically necessary by your PCP.
Signature*

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New Patient Enrollment

Demographic Information

In Case of Emergency

Family Members

Insurance Information

Authorization for Treatment of Minor

Edmond Pediatrics Vaccination Policy Agreement

Edmond Pediatrics Photo Consent

Patient Portal Enrollment

DLO Acknowledgement

Acknowledgment of Privacy Practices and Consent

Financial Policy

Late Arrival, Incorrect Location, & Missed Appointments Policies

Medical Home Agreement