Patient Registration Form and Consents

Guarantor Information (Person financially responsible)

Policy holder (if different from the patient)

I hereby authorize (when I am unavailable to give consent) to the following individual(s)

to consent to any, and all medical care and attention for this child which is deemed necessary healthcare provider licensed in the state of Texas. This consent includes, and appropriate by a but Is not limited to, medical and surgical intervention and elective as well as emergency care. This delegation shall be valid until I withdraw delegation of consent.

Kids GI Kare is committed to providing the highest quality health care for your child. As part of your relationship with Kids GI Kare a clear understanding of our financial policy is important so you will know what actions Kids GI Kare will be undertaking on your behalf as well as what your financial responsibilities

Your health Insurance policy is a contract between you and the insurance company. Kids GI Kare, as a courtesy to you, will bill your primary company for all services rendered, with the information you have provided us. You have certain responsibilities to ensure that proper, accurate and timely submission of charges occurs. You are required to present your primary insurance card at the time of service, and to Inform us as soon as possible of any changes of your carrier or policy information. Any unpaid claims because of wrong given Information will be the patient's responsibility. You are responsible to be familiar with your plan benefits, whether it is a copay or a deductible plan, and what services it covers. You are responsible for payment of all services provided by your pediatrician. Co-payment for services, in accordance with your insurance benefits, is due at the time of service.

Remaining Balance After Your Insurance Company has pain): Kids GI Kare will submit a claim to your primary health Insurance company for services provided. Any balance remaining following adjudication of this claim is your responsibility. This balance may include your deductible, coinsurance and any, and all charges not covered by your insurance company. Payment for this balance is due upon receipt of your billing statement. In the event a bill goes unpaid without contacting our billing department to discuss payment option, the account will be turned over to a collection agency. No Show Policy:

Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. Therefore, Kids GI Kare reserves the right to charge a fee of $ 50.00 for all missed appointments that are not cancelled with a 24-hour advance notice. Multiple "no shows" in any 12 months period may result in termination from our practice.

Request for Medical Records: $25 All daycare/school forms, to include school letters and all other forms If not filled out at the time of exam, will acquire a fee of $10.00. Returned checks: $30 After hours, weekend, and holiday appointments - $20.

Ihave read the above financial policy for Kids Kare Pediatrics and I agree to the terms listed above.

I voluntarily authorize and consent to the medical care, treatment, and diagnostic tests that Kids GI Kare and its designated associates are necessary for this child. I understand that by signing this form, I am giving permission to the doctors, nurses, physician assistants and other healthcare providers in this medical office to provide treatment to this child as long, as this child is a patient in this office, or until I withdraw

CONSENT TO RELEASE AND OBTAIN INFORMATION

I agree to allow Kids GI Kare to deliver the necessary care to this child to provide continuity of care and treatment. Kids GI Kare providers may obtain from any source and examine and use, or discuss and disclose, the patient's medical record and information to other healthcare providers, medical records auditors, professional committees, care evaluators and governmental agencies. This information can include, but is not limited to medical history, examinations, diagnoses, treatments any psychiatric, drug and alcohol abuse or genetic testing information, or HIV or AIDS Information. This consent to release and obtain information is valid until revoked. The undersigned may revoke the consent in writing at any time, except about disclosures that have already been made in reliance on such consent.

PRESCRIPTION MEDICATION CONSENT FORM

I voluntarily authorize Kids GI Kare to allow E-Prescribing for the patient's mail order prescription, which allows healthcare providers to electronically transmit prescriptions to the pharmacy of my choice, review pharmacy benefit information and medical dispense history as long, as this child is a patient at this office, or until I withdraw my consent.

Each time the patient misses an appointment without providing a proper notice, another patient is prevented from receiving care. Therefore, Kids GI Kare reserves the right to charge a fee of $ 50.00 for all missed appointments ("no shows") and appointments which, absent a compelling reason, are not

cancelled with a 24-hour advance notice.

"No Show" fees will be billed to the patient. This fee Is not covered by Insurance and must be paid prior to your next appointment. "no shows" In any 12- month period may result in termination from our

Thank you for your understanding and cooperation as we strive to best serve the needs of sill of our patients.

By signing below, you acknowledge that you have received this notice and understand this policy,

1. I understand that my health care provider wishes me to engage in a telemedicine consultation.

2. I understand that video conferencing technology used will not be the same as a direct patient/health care provider visit due to, the fact that, I will not be in the same room as my healthcare provider.

3. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider can discontinue, or I can discontinue the telemedicine consult/visit if It is felt that the video conferencing connection are not adequate for the

4. I understand that my healthcare Information may be shared due to billing purposes.

5. I understand the alternative to telemedicine will be coming to the office, and in choosing to participate in a telemedicine consultation. I understand that some parts of the exam Involving physical test may be conducted by individuals at my location at the direction of the consulting health care provider.

6. I understand that telemedicine consult time is based on availability of the physician and Incase of urgent need for a consult It may be better to consider going to local urgent care of ER for faster access.

7. I understand I will be responsible for a $20 NON-REFUNDABLE convenience fee and any copay/deductible per my insurance benefits.

8. I understand my picture might be taken to be used for documentation purposes.

9. I authorize provider to use my personal email address to send any lab/imaging orders that will be

Name of sending person/organization/healthcare provider.

I understand that this authorization shall be valid for one year. I understand that I may revoke this consent at any time except to the extent that action has already been taken.

I understand that a reasonable fee may be charged for duplication of records. An estimate of those charges will be provided upon request prior to duplication.

The requestor may be provided with a copy of this authorization.