New Patient Form

PATIENT DEMOGRAPHICS
PATIENT First Name*
PATIENT Last Name*
MI
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex*

MaleFemale
Preferred Language
Ethnicity: (check one)

Hispanic or LatinoNot Hispanic or LatinoUnknown
Race: (check one)

American Indian or Alaska NativeBlack or African AmericanAsianNative Hawaiian / Other Pacific IslanderWhiteOtherDecline to Specify
PARENT INFORMATION
#1 PARENT Information

MotherFatherOther guardian, foster parent, etc
First Name*
Last Name*
MI
Date of Birth*

MonthDayYear
Date
SSN*
Email Address*
example@example.com
Home Phone*
Cell Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Employer
Address: Same as Patient

YesNo (If No, please complete below)
Street Address
City
State
Zip
Enter Information for PARENT #2

YesNo (skip)
#2 PARENT Information

MotherFatherOther guardian, foster parent, etc
First Name
Last Name
MI
Date of Birth

MonthDayYear
Date
SSN
Email Address
example@example.com
Home Phone
Cell Phone
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Employer
Address: Same as Patient

YesNo (If No, please complete below)
Street Address
City
State
Zip
Primary Care Physician: (PCP)
Emergency Contact Name (Person not living with patient)
Emergency Contact Relationship to Patient
Emergency Contact Phone Number
How did you hear about our clinic

friend/relative,medical provider,phone book,billboard,internet
Signature of Parent/Legal Guardian/Representative*

Clear
Date

MonthDayYear
Date
Relationship to Patient
INSURANCE INFORMATION
Please complete all information so that we can bill your insurance correctly. A copy of your current insurance card(s) is required for each appointment. Patients with no insurance are required to pay 50% of their charges at time of service. Co pays or patient responsibility percentages are due at time of service. Thank you for your cooperation.
PRIMARY Insurance Company*
Name of Insurance Holder*
Address of Insurance Holder (if different from patient)*
Relationship to Patient
Date of Birth*

MonthDayYear
Date
SSN*
Policy Number*
Group Number
Effective Date

MonthDayYear
Date
PRIMARY Insurance Claims Address*

Claims Address

Street Address Line 2

CityState

Zip
Do you have SECONDARY Insurance?

Yes (If Yes, please complete below)No
SECONDARY Insurance Company (if applicable)
Name of Insurance Holder
Address of Insurance Holder (if different from patient)
Relationship to Patient
Date of Birth

MonthDayYear
Date
SSN
Policy Number
Group Number
Effective Date

MonthDayYear
Date
SECONDARY Insurance Claims Address

Claims Address

Street Address Line 2

CityState

Zip
Do you have TERTIARY Insurance?

Yes (If Yes, please complete below)No
TERTIARY Insurance Company (if applicable)
Name of Insurance Holder
Address of Insurance Holder (if different from patient)
Relationship to Patient
Date of Birth

MonthDayYear
Date
SSN
Policy Number
Group Number
Effective Date

MonthDayYear
Date
TERTIARY Insurance Claims Address

Claims Address

Street Address Line 2

CityState

Zip
Does this information pertain to any other siblings?

Yes (If Yes, list names and birthdates below)No
Sibling #1
Name and Birthdate
Sibling #2
Name and Birthdate
Sibling #3
Name and Birthdate
Sibling #4
Name and Birthdate
Sibling #5
Name and Birthdate
Sibling #6
Name and Birthdate
Signature of Responsible Party*

Clear
Date

MonthDayYear
Date
PEDIATRIC HEALTH QUESTIONNAIRE
Patient Current Age
ie. 4 yrs or 18 mo
Are you the parent or legal guardian for the child being seen today?

YesNo
If not, do you have written permission allowing us to treat the child?

YesNo
Is the child currently taking any medications (over the counter or prescription)?

YesNo
If so, please list the medication(s) and the current dosage(s)
Medication #1
Dosage
Medication #2
Dosage
Mother’s Prenatal History (If Known)
Number of pregnancies
Number of deliveries
Number of living children
Number of adopted children
Number of miscarriages
Have any children died?

YesNo
Please check any complications during pregnancy with this child

Abnormal bleedingAccidentsBlood transfusionsElevated blood pressureElevated blood sugarX-raysRash with feverPre-mature laborHospitalizationKidney infectionsswelling (eyes, face, hands)Venereal diseaseExcessive nausea/vomiting
Were any medications other than Vitamins or Iron taken during pregnancy?

Yes (If Yes, explain below)No
Please list medications
Neonatal History
Did labor last longer than 24 hours?

YesNo
Delivery timing

On Time (full-term)Early (pre-term)Late (post-term)
How many weeks Gestation?
Was child born

C-sectionHead firstFeet firstButtocks first
Did child require

Photo-therapy,IV fluids/antibiotics,Oxygen,Prolonged hospital stay,NICU Stay
Birth weight (lbs)
Lbs
Birth weight (oz)
Oz
Birth Length
Inches
In the first six (6) weeks of life, did child have any of the following problems?

Difficulty breathing,Blue spells,Yellow Jaundice,Vomiting,Loose stool,Colic,Formula changes,Fever/infections,Seizures,Weight loss,Blood transfusions,Surgery.
Nutritional History
Was child Breast fed?

YesNo
Until what age?
Bottle fed?

YesNo
Formula brand?
Any feeding problems?

YesNo
If yes, please explain
Does child have

constipation,diarrhea.
Any current concerns about child's nutrition?

YesNo
If yes, please explain
Developmental History
Did your first child develop normally?

YesNo
If no, please explain
Any history of speech/language delay?

YesNo
Any concerns with child’s current development?

YesNo
If yes, please explain
Immunization History
Is child current on his/her immunizations?

YesNo
Any adverse reactions to previous immunizations?

YesNo
When was child's last Tetanus booster vaccination?

MonthDayYear
Date
Past Medical History
Has child had any of the following

ADD/ADHDAllergic RhinitisAsthmaAutismBehavioral prob.Bladder problemsBone problemsCerebral PalsyChicken PoxDown SyndromeEye problemsFrequent UTI’sHearing problemsHeart problemsIntestinal prob.Kidney problemsMuscle problemsPneumoniaRash/EczemaRecurrent Ear infRoseolaRSVSeizuresSinusitisScarlet FeverSpina BifidaStomach problemsStrep ThroatDiabetesWhen was child’s last Tetanus booster vaccination?
Please list any previous Emergency Room visits, hospitalizations or surgeries with dates:
Medication/ food allergies and reactions:*
Type "None" if there are no allergies
Family History
Have any of the child’s blood relatives had any of the following:

ADHDAlcoholismAllergic RhinitisAnemiaAsthmaArthritisBirth defectsBlindnessBreast CancerCataractsChildhood CancerCongenital Heart DiseaseCystic FibrosisDeafnessDrug DependenciesDepressionDiabetesEczemaHeart attackHIV/AIDSHypertensionKidney DiseaseLeukemiaLiver DiseaseMental RetardationLupusMigrainesMultiple SclerosisPsychiatricSickle Cell AnemiaSeizuresSkin CancerStrokeThyroid DiseaseTuberculosisUrinary Tract InfectionInformation not known about biological family membersOther
Social History

These questions relate to the houshold in which the child lives:
Number of siblings
Birth Order
(first, middle, etc...)
Smokers in the house:

YesNo
Number of dogs
Number of cats
Other pets
Substance abuse:

YesNo
Discipline problems:

YesNo
Temper problems:

YesNo
Deceased parents

YesNo
Divorced parents:

YesNo
State custody:

YesNo
I certify that the above information is true and correct to the best of my knowledge.
Signature*

Clear
Printed Name*
Relationship to Patient
Date

MonthDayYear
Date
PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
I hereby give my consent for Mountain West Pediatrics (MWP) to use and disclose Protected Health Information (PHI) about me to carry out Treatment, Payment and Healthcare Operations (TPHO

I have the right to review the Notice of Privacy Practices, which provides a more complete description of such uses and disclosures, prior to signing this consent. MWP reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by sending a written request to MWP at the above address.

With this signed consent, MWP may call my home and any other locations for which I have provided contact information in order to relay or gather information to assist MWP in carrying out TPHO; including, but not limited to, appointment reminders, insurance and billing items, calls regarding my clinical care and laboratory results. MWP may give the message in person, leave a message on voice-mail or send the message via email to any email address I have provided to them.

I have the right to request MWP restrict how it uses or discloses my PHI in order to carry out TPHO. Any such request must be submitted in writing to MWP. I understand that MWP is not required to agree to my requested restrictions, but if they does so in writing, they are bound to such agreement.

By signing this form, I am consenting to MWP the use and disclosure of my PHI in order to carry out TPHO. I may revoke my consent at any time in writing, to the extent that MWP has already made disclosures in reliance upon my prior consent. If I do not sign this form, or revoke it at a later date, MWP may decline to provide treatment to me.
Signature of Parent or Legal Guardian*

Clear
Date

MonthDayYear
Date
MOUNTAIN WEST PEDIATRICS FINANCIAL POLICY
- Insurance companies are not designed to pay the entire fee associated with an office visit. All co-payments, deductibles, and non-covered services must be paid in full at the time of service by the person accompanying the patient regardless of health insurance coverage arrangements or court directives (in the case of estranged or divorced parents For those with a deductible plan, $70.00 toward the balance is due at the time of service. You will be billed for the remaining balance. A $10.00 charge may be added to your account for billing costs of the required co-payment that is not made at the time of service.
- Patients without insurance will be Self-Pay. A $95.00 payment for service is due prior to services being rendered.
- Our office will submit claims to your insurance company as a courtesy service to you. It is important and your responsibility to know what services your insurance plan covers; we take no responsibility to know what services your insurance plan covers. Services that we render that are not covered by your insurance plan are your financial responsibility. We emphasize, as your health care providers, that our relationship is with you, not your insurance company.
- If your insurance company requires laboratory specimens to be sent to a specific lab, it is your responsibility to know the participating lab(s Locally we can send labs to LabCorp, Quest, or the lab at Mountain West Medical Center. Please make us aware when labs are ordered before leaving the office.
- I authorize payment of medical benefits directly to Jim J Gould, MD dba. Mountain West Pediatrics.
- I authorize use of my signature on all insurance claim submissions.
- I understand that a finance charge of 1.5% per month (18%APR) of unpaid balances will be added to my account. If there is a delinquent balance (3 statements sent after insurance payment or 3 statements after a self-pay visit) the account may be sent to Express Recovery Collection Services. I agree to pay up to an additional 40% collection fee and all associated court costs/legal fees with or without suit. If I have opted out of receiving a final notice for delinquent accounts by text or email, see contact options below, I understand a letter via certified mail or priority mail will be sent. In sending this letter, a fee of up to $6.00 will be added on top of the additional collection fee.
Contact Options:
- We want to stay in touch with you regarding your account and its collection status. In order for us to contact you regarding all past due accounts and any collection status you may have, you expressly authorize us to contact you by the telephone by sending text messages or emails at any number or email you have listed. You acknowledge that such contact could result in charges to you by your telephone carrier. Methods of contact may include the use of pre-recorded/artificial voice messages and /or the use of an automatic telephone dialing system, as applicable. You acknowledge and agree that this authorization shall extend to any billing or collection company or companies which may be assigned.
Yes, I authorize this (initials)
No, I do not authorize this (initials)
FINANCIAL POLICY (CONTINUED)
- I understand a bounced check charge of $20.00 will be applied for all returned checks.
- I authorize Jim J. Gould, MD or any assistants to take my detailed medical history and to perform any necessary examination to confirm the condition for which I seek medical attention and to perform such procedures that are in their professional judgment necessary and or desirable for your child’s well-being. Parents will be very involved in this decision making process.
- I authorize the release of information necessary to process insurance claims and to request payment of benefits to be made for services rendered.
- No show appointments: We are in the business of taking great care of your children and their healthcare needs. A missed appointment is a missed opportunity for someone else’s child that may need to be seen. Our policy, as a benefit for you, is to call and remind you the parent (guardian) of your child’s upcoming appointment 1 weekday prior to the appointment. We can only provide this service if we have correct phone numbers on file. I agree to give 24 hours’ notice for any cancellation of appointments. A fee of $50.00 will be applied to your account for missed appointments without prior cancellation. If you have made an appointment for the same day and you do not show for the appointment, a $50.00 fee will be applied to your account.
- I understand that if I am more than 15 minutes late for the scheduled appointment for my child, I may be asked to reschedule.
- If you are experiencing a financial hardship, please discuss this with the billing office staff. We will gladly work with you to
- make payment arrangements. Our billing company, Alta Billing can be reached at 435-215-7901.
- If you are bringing your child in for a preventative visit and an acute issue is addressed, be advised that an acute issue may be billed to your insurance as a separate encounter and you may incur additional charges that will be your responsibility. Preventative and sick visits should be scheduled separately so that adequate time is spent on each visit.
By signing this form, I acknowledge that I fully understand and agree with the above policies and procedures.
Signature of Parent or Legal Guardian*

Clear
Date

MonthDayYear
Date
Should be Empty:

PATIENT DEMOGRAPHICS

PARENT INFORMATION

INSURANCE INFORMATION

PEDIATRIC HEALTH QUESTIONNAIRE

Mother’s Prenatal History (If Known)

Neonatal History

Nutritional History

Developmental History

Immunization History

Past Medical History

Family History

Social History

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

MOUNTAIN WEST PEDIATRICS FINANCIAL POLICY

Contact Options:

FINANCIAL POLICY (CONTINUED)