Child's Information

PLEASE NOTE, UNLESS THE PERSON IS LISTED ABOVE, WE CAN NOT RELEASE INFORMATION OR ALLOW YOUR CHILD TO BE SEEN WITHOUT YOUR WRITTEN CONSENT DUE TO PRIVACY LAWS. I ACKNOWLEDGE THE ABOVE LIST OF PEOPLE,

Birth and Medical History

Current and Past Medical Problems including surgeries (please list - if none leave blank):

Current Medications and Dosages (please list separately- if none leave blank):

Family History - please Mark Yes only to those that apply and write what family member has it 

Consent for Disclosure of Protected Health Information for purposes of treatment, Payment and Healthcare Operations

I consent to the use or disclosure of my child's protected health information by Pelican Pediatrics, LLC for the purpose of diagnosing or providing treatment to my child, obtaining payment for my health care bills or to conduct health care operations of Pelican Pediatrics, LLC. I understand that diagnosis or treatment of my child by Pelican Pediatrics may be conditioned upon my consent as evidenced by my signature onthis document. I also consent the use of my email address if provided to be used in correspondence with Pelican Pediatrics in the care of my child. I understand I have the right to request a restriction as to how my child's protected health information isused or disclosed to carry out treatment, payment or healthcare operations of the practice. Pelican Pediatrics, LLC is not required to agree to the restrictions that I may request. However, if Pelican Pediatrics, LLC agrees to a restriction that I request, the restriction is binding on Pelican Pediatrics, LLC. I have the right to revoke this consent, in writing, at any time, except to the extent that Pelican Pediatrics, LLC has taken action in reliance on this consent for treatment. My child's "protected health information" means health information, including demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies my child or myself, or there is a reasonable basis to believe the information may identify my child. I understand I have a right to review Pelican Pediatrics, LLC's Notice of Privacy Practices prior to signing this document. Pelican Pediatrics, LLC's Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my child's protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of the Pelican Pediatrics, LLC the Notice of Privacy Practices for Pelican Pediatrics, LLC is posted in the reception area of the office. This Notice of Privacy Practices also describes my rights and the Pelican Pediatrics, LLC's duties with respect to my child's protected health information. Pelican Pediatrics, LLC reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my child's current or future appointments.

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

I hereby authorize information to be released from:

I request and authorize the facility or provider named above to release health care information for the above listed child to Pelican Pediatrics, LLC by Fax: (843) 795-3143 The type of information to be used or disclosed is as follows: Immunization records, Entire Medical Records This protected health information is being used for the following purpose: Healthcare Provider Continuity of Care

This authorization shall be in force and be in effect for 1 year from date below, unless otherwise specified at which time this authorization to use or disclose this protected health information expires. Iunderstand that the information in my child's health records may include information relating to sexually transmitted diseases, acquired immunodeficiency Syndrome (AIDS), or human immunodeficiency virus (HIV It may include information about behavioral or mental health services and the treatment for alcohol and drug abuse. Iunderstand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to Pelican Pediatrics, LLC at 452 Folly Rd., Charleston, SC 29412. I understand that a revocation is not effective to the extent that Pelican Pediatrics, LLC has relied on the use or disclosure of the protected health information. Iunderstand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or South Carolina law. Pelican Pediatrics, LLC will not condition my treatment, payment, enrollment (if applicable) in a health plan or eligibility for benefits on whether I provide authorization for the requested use or disclosure. Iunderstand that I do not have to sign this authorization in order to obtain Healthcare treatment.

Pelican Pediatrics Vaccination and Preventative Care Policies

Vaccines: are the greatest medical-scientific discovery of our lifetime. They save millions of lives worldwide every year and one of the most important parts of preventative care. We follow the CDC immunization schedule as it is the only schedule that has actually been well studied and is safe and effective. Although we realize there are other "alternate schedules" out there, they are generally one person's opinion and not studied. We do not encourage alternate schedules as they increase the likelihood of someone being under immunized and therefore at risk of illness or of someone getting an extra unnecessary vaccine. If you have any specific questions about vaccinations, our doctors are happy to answer them for you.

We practice evidence passed medicine, therefore as a practice policy, Pelican Pediatrics does not accept families who do not immunize or who refuse any of the recommended vaccines. We are happy to answer any questions you may have but if you chose not to immunize your child we can recommend another practice that would be more fitting for your needs.

Preventative Care: We believe that preventative care is an integral part of keeping children healthy. We follow the American Academy of Pediatrics Bright Futures guidelines for well visits and developmental and emotional screenings. This includes annual well child visits for children age 3 and older even if they are well. We require that our patients have those well visits annually. Although these visits are universally covered by insurance, some insurances cover one every calendar year, some anytime after child's birthday, some require exactly 365 days in between. It is your responsibility to find out your insurance requirements and schedule accordingly. Families who consistently miss or chose not to schedule these annual visits, will not be able to schedule sick visits.

I agree to abide by the Pelican Pediatrics vaccination and preventative care policy and understand that if I chose to not vaccinate my child, or not have regularly scheduled visits, my family will be asked to find another primary care physician.

Missed appointment policy: When families miss appointments their child's medical, emotional, and preventative care needs get missed. In addition, it takes away appointment slots from other children who need to be seen. We understand that emergencies happen but request that you notify us 24 hours before the appointment time if your child has to miss an appointment so it can be offered to another child. If a child or family consistently misses appointments without prior notification, they may be asked to find another provider. I agree to abide by the Pelican Pediatrics missed appointment policy:

Custody/Separation/Divorce: Pelican Pediatrics strives to provide your child the best medical care no matter what the parental relationshipis. We are not judges nor lawyers and will not be taking sides in cases of divorce or separation. We expect both parties to be civil when receiving care and in all communications with Pelican Pediatrics and our staff. In the case of separation, divorce, change in custody it is the guardian's responsibility to provide us with any applicable court orders. Unless we have paperwork that tells us otherwise, both parents will have access to a child's medical record and be able to seek care.

I agree to abide by the Pelican Pediatrics custody policy:

Insurance: As a courtesy to our patients, we will file the forms necessary so that you receive the full benefits of your medical coverage. It is your responsibility to provide Pelican Pediatrics with your updated insurance and if applicable, secondary insurance. We ask that you read your insurance policy to be fully aware of any limitations of the benefits provided. If your insurance company denies coverage, or we otherwise do not receive payment 60 days from filing your claim, the amount will then become due and payable by you. Remember that your coverage is a contract between you and your insurance company and/or your employer and your insurance company. Although we will make a good faith effort to assist you in obtaining your benefits, we cannot force your insurance company to pay for the services we have provided to you.

NEWBORNS: Most insurance plans require that a newborn be added to the parent's insurance plan within the first 60 days of life. It is your responsibility to contact your insurance company and have your baby added to the plan. If your baby is not added in a timely manner, you will be responsible to pay for any services incurred prior to the insurance becoming active.

Copayments and Deductibles: Depending on your insurance policy, a copayment and/or deductible or coinsurance may be required at the time of service. Please note that the copayment is a contractual requirement from the insurance company and cannot be written off by the clinic. If you participate in a High Deductible Health Plan (HDHP) and have not yet paid your deductible in full, it is likely that any non-preventive services will require payment at the time those services are rendered. Coinsurance may apply even after meeting your deductible.

Patients Without Insurance/Non-covered expenses: For patients without insurance a time of service discount will be applied to the bill if settled in full on the day of service. This discount does not apply after the day of the visit. The same discount will be applied to any noncovered charges for patients with insurance, if paid at the time of service. There may be charges that are not collected of billed that for extra tests and procedures that you will be billed for and expected to pay.

Financial Hardship: Because we realize that every person's financial situation is different. If you are uninsured and unable to pay the reduced self-pay rate, please contact the office administrative staff for an application to see if you qualify for our sliding scale based on financial need.

Medicaid: Pelican Pediatrics accepts all forms of SC Medicaid. It is your responsibility to make sure you do your child's annual renewal so that your child's Medicaid doesn't lapse or you may be responsible for services rendered. It is also your responsibility to notify Pelican Pediatrics if your child has other insurance in addition to Medicaid at the time of service or you may be responsible for services rendered. Returned checks: will be subject to a $35 returned check fec.

Patient/Parent/Guardian Responsibility: I understand that whomever accompanies my child to their appointment has authorization to consent to medical care as needed, and is responsible for payment of medical services. I acknowledge my responsibility for payment of all services provided by Pelican Pediatrics in accordance with the practice's fees and terms. In the cases where a custody plan exists, the parent that brings the child in for the appointment is considered the guarantor and is responsible for payment.

Late Fees: I understand that my account becomes delinquent if not paid within 30 days. Any delinquency post 90 days will warrant the balance and any administrative fees being assigned to a collection agency.

Assignment and Release: I authorize payment to be made directly to Pelican Pediatrics by my insurance company, and I accept financial responsibility for all services not covered by my insurance. I authorize release of any medical care information requested by my insurance company. I agree to abide by the Pelican Pediatrics financial policy:

Credit Card on File Policy: Pelican Pediatrics is committed to making our billing process as simple and easy as possible and as touch-free as possible. We encourage that all patients provide a credit card on file with our office. We will scan your card with a card reader. It will be encrypted, protected by a payment gateway, kept off-site, and inaccessible to all Pelican Pediatrics employees. Credit cards on file can be used to pay copays at the time of the visit as well as other charges (such as toward the deductible or for non-covered services Once processing the visit with your insurance, you may owe part of the patient responsibility fee. If we do not receive payment for the amount listed on your statement within 14 days, we will run the credit card on file for the full amount owed provided it is under $200. For any amount larger than $200 we will first call you to confirm that is the method of payment you prefer. If your payment is declined, we will call you. If our reminder call is not returned within one week, a $35 declined payment fee will be applied, and another statement will be mailed. Your account becomes delinquent if not paid within 30 days after the date of the original statement. Further delinquency will be subject to collections with additional finance fees.

For families who do not wish to leave a credit card on file, you will be obligated to maintain a $50 balance, per child, with the practice. That balance will be used for any unpaid patient responsibility, as outlined above, and will need to be replenished before a member of the family can be seen in the practice again. By signing below, I give Pelican Pediatrics permission to charge my credit card for any copay or patient balance due on my account under $200. I will be asked to present my card at my first visit to have it stored in a secure system. If I have insurance coverage, with the exception of Copay that will be charged at the time of the appointment, my card will be charged the balance AFTER my insurance has paid their portion.

Note: The patient (or guarantor) must sign this sheet and present valid photo identification before the patient can be seen.

This is for your protection and to prevent fraud.