Patient Intake Form

Please list family members who live at home or are regularly around your child. List their name, relationship to patient, their DOB, their employer, and whether they are living at home and whether they are a smoker

The following statement of your rights and responsibilities is presented as the policy of The Children’s Clinic of Conway & Greenbrier but does not presume to be a complete representation of all mutual rights and responsibilities.

You have the right:

• To impartial access to the medical resources of The Children’s Clinic of Conway & Greenbrier without regard to race, color, national origin, age, sex, handicapping or disabling condition, spiritual or ethical beliefs or source of payment.
• To receive considerate, respectful care, which always recognizes your child’s personal dignity and under all circumstances.
• To participate in decisions involving your child’s care. Expect in emergency, your child shall not be subjected to any procedure without your voluntary, competent, and understanding consent or the consent of your legally authorized representative.
• To refuse treatment to the extent permitted by law and to be informed of the consequences of that refusal.
• To instructional and educational information about your child’s medical treatment in a language and terms that you understand.
• To the confidential treatment of and personal access to your child’s medical record.
  To know who is responsible for providing your child’s direct care and to receive information
  concerning your child’s continuing health care needs and alternative for meeting those needs.

You have the responsibility:

• To give your provider and The Children’s Clinic of Conway & Greenbrier staff complete and accurate information about your child’s condition and care.
• To follow instructions of your provider and the staff of The Children’s Clinic of Conway & Greenbrier and to keep appointments relative to your child’s care.
• To make it known whether you clearly understand planned actions and treatment and what is expected of you.
• To report unexpected changes in your child's condition to your provider or staff of The Children's Clinic of Conway & Greenbrier.
• To accept the financial obligations associated with your child's care.
• To advise your provider or any office staff members of any dissatisfaction you may have regarding your child’s care.
• To be considerate of other patients and of staff members who are caring for your child.
• To bring a current copy of any advance directives at the time of the first visit to be placed in your medical record.

Professional services are charged to the patient, not the insurance company. This office does not accept responsibility for collecting your insurance claim, or for negotiating a settlement on a disputed claim.

I hereby authorize Conway Children’s Clinic to furnish information to insurance carriers concerning my child’s illness and treatments and I hereby assign to the physician all payment for medical services rendered by insurance.

The patient will be responsible for all co-payments, deductibles, and co-insurances which are due at the time of service.

It is the patient’s responsibility to keep us updated on correct insurance information. If you do not tell us about changes or pending changes, you could incur charges that may or may not be covered by your insurance.

We verify most insurances as a courtesy, however, there is no way we can determine all your benefits so we cannot guarantee what may or may not be covered by your plan until the claim is processed. Examples may include:

Well Child exams and immunizations. Not all plans cover these. Some may only cover to a certain age and some only cover up to a certain dollar amount. Some plans may pay 100% and others may still charge copay. Please be familiar with your plan to know what may or may not be covered as you will be responsible for any charges incurred.

Some procedures, such as laceration repair and wart removal may be processed at a different benefit level other than just a routine office visit and could be subject to deductibles and co-insurances.

Some plans exclude certain diagnoses. There is no way we can make that determination when we check eligibility, and you may be responsible for those visits.

Diagnoses such as ADHD may be covered by mental health benefits and could be subject to deductibles.

Statements are mailed out weekly. Payment is due within 15 days of receipt. Any balances over 90 days with the patient receiving at least 3 statements with no activity can be turned over for collections and you could be discharged from the clinic.

We do not get involved in separated and divorced parents’ financial obligations. We will send the statement to whichever parent is listed as the guarantor and we hold both parents responsible for any outstanding balances.

** I authorize The Children's Clinic of Conway & Greenbrier to store my credit card information on file.

For families who are ongoing patients of The Children’s Clinic of Conway & Greenbrier. Please fill out the following information for those you would like to give permission to bring your child/children to our clinic.

I (we) appoint:

as my (our) proxy decision maker for consenting to non-urgent medical care for my (our) children listed below. I (we) have the legal right to delegate such consent to the proxy decision maker, who is an adult and legally and medically competent to exercise the authority so delegated. Be advised that protected health information may be shared with the proxy to facilitate informed decision making.

Limitations

Identify any limitations on the kinds of medical services for which this consent by proxy is given. If none, state "none".

Identify any limitations on the time frame for which this consent by proxy is given. If none, state "none".

The Children’s Clinic of Conway & Greenbrier see patients by scheduled appointment and for emergencies. We try to see all those who need appointments with an appropriate amount of time allotted for each visit.

We reserve time for each patient, and if the patient does not come to the appointment the result is lost revenue to the clinic and a missed opportunity for someone else to be given the appointment time.

To address the problem of frequent missed appointments (often multiple missed appointments within a family) and provide appointments for as many patients as possible, we have instituted a financial penalty for people who repeatedly miss appointments.

Arriving 20 minutes late to an appointment is the same as missing an appointment, and in most cases, you will be asked to reschedule the appointment and pay the fee.

Canceling an appointment less than an hour before the appointment is the same as a missed appointment. Call the day before or early in the day if you need to cancel or reschedule an appointment.

Missed appointments within a family are tracked together. If two children each miss one appointment, it counts as two missed appointments for your family.

Parent or guardian, please read all the above, and read and sign below:
I understand that for each missed appointment I will be charged a $25 or $35 fee, PAYABLE BEFORE FURTHER APPOINTMENTS ARE SCHEDULED, and that if I repeatedly miss appointments, I will be asked to find another doctor for my children. I understand that Medicaid, ARKids, and private insurance do not cover these costs and I will be expected to pay the clinic directly.

This is the facility receiving the medical records. Thus, The Children's Clinic is pre-populated here.

 

I request that my protected health information be disclosed to (Practice acquiring records):

Below you are authorizing which records should be sent by the previous medical facility to The Children's Clinic.

I authorize the following protected health information to be released from my medical record(s):

I understand that the information in my medical record may include information relating to sexually transmitted disease (STD), Acquired Immunodeficiency Syndrome (AIDS), or Human  Immunodeficiency Virus (HIV). It may also include information about behavioral or mental health services, and alcohol or drug abuse. Federal law protects the following information. If this information applies to you, please indicate if you would like this information released/obtained (include dates where appropriate):

By signing this authorization form, I understand that:
1. I have a right to withdraw this authorization at any time. Request to withdraw must be made in writing and presented to Practice. I understand that stopping this release will not apply to information that has already been released.
2. This authorization will expire (insert date or event below). If I fail to specify an expiration date or event, this authorization will expire 90 days from the date it was signed.
3. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this authorization.
4. Once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by the federal privacy laws or regulations.
5. I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits. I may inspect or obtain a copy of any information used or disclosed under this authorization.
6. Requests for copies of medical records are subject to reproduction fees in accordance with federal/state regulations.

I authorize the release of any personal health information necessary to process insurance claims for services rendered and any other avenues used for collection of balances. I authorize any benefits on my behalf and request that payment be made directly to the practice. I authorize access to the pharmacy benefit manager, PBM, as needed by my physician (provider). I understand that I am responsible for the balance of my account. Upon receipt, if I should receive payment from my insurance company, I also understand that I am responsible for my co-payment, deductibles, or balances as determined by my insurance carrier. I have been informed of this office’s HIPAA policy and offered a copy of such.

Telephone, Cell phone, and Electronic Communication
I authorize The Children’s Clinic of Conway and Greenbrier (also known as Conway Children’s Clinic and Greenbrier Children’s Clinic) to use my provided phone number(s) and email address, included in the new patient paperwork and/or listed in the electronic medical record, for the following:

• Appointment reminders
• Follow-up reminders
• Patient communication
• Billing communication
• Clinical reminders

These communications may be subject to carrier charges, if applicable, per the phone or mobile plan provided by the caregiver’s cell phone carrier.

The Children’s Clinic of Conway and Greenbrier will treat any email address or phone number I provide as my private email address and phone number and this contact information will not be shared by any third-party entities.

The Children’s Clinic has a patient portal via InteliChart. InteliChart provides a user-friendly interface that is compatible with most web browsers and is mobile friendly. There are also apps available for both iPhone and Android operating systems. Electronic communication, listed above, will be used to enhance our patient care. Communication with The Children’s Clinic, including appointment requests, refill requests, and general messages is preferred through the patient portal.

For security, InteliChart requires any new registration with their service to be via invitation only. This invitation will be sent by an employee of The Children’s Clinic.

The patient portal invitation will be sent via the method checked on page one of the New Patient Paperwork. If this page is provided on its own, please list the preferred method of delivery for the portal invitation:

[LEFT BLANK INTENTIONALLY AS THIS QUESTION IS ANSWERED ON PAGE 1]

Invitations are patient specific. Any siblings that need to be added to the portal need their own invitation. Please indicate any siblings below:

The Children’s Clinic of Conway & Greenbrier
Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice provides you with information on the steps this clinic has taken to protect the privacy of your protected health information. It also describes some of the privacy rights you have and how you can exercise those rights. If you have any questions, please ask the receptionist if you can speak with Amy Irby or Teresa Kelley at (501)327-6000 or (501)679-6796, who are our Privacy Officials.

Your Protected Health Information is the information that is created or received by this clinic, transmitted by electronic form or maintained in any medium, that identifies you or could reasonably identify you, and relates to your past, present, or future.

1. physical or mental health or condition;
2. your health care treatment; or
3. the payment of your health care services.

1. USES AND DISCLOSURES:

1. The following are examples of some of the ways the Clinic may use and disclose your Protected Health Information (PHI) based on your signing our Clinic's consent form:
   1. Treatment: In order to adequately provide for your health care needs, your PHI will be used and disclosed within the Clinic by the Clinic’s employees and independent contractors as necessary to treat, evaluate and provide you with health care services. This may also include the need for us to obtain PHI from your previous health care providers for us to treat you properly.
   2. Payment: To receive payment for our services, the Clinic will have to disclose certain PHI to your Health Plan or Insurer. This could require disclosure prior to treatment to obtain pre-certification from your Insurer to perform a procedure or it could be a post-treatment disclose to obtain payment for the services provided.
      Your insurer also has a right to demand access to your records to determine eligibility for making pre-existing condition determinations or for conducting quality control inspections. PHI may also be disclosed to comply with workers compensation laws and similar programs.
   3. Clinic Operations: To ensure the proper functioning of our clinic, it may be necessary that certain PHI be used and disclosed. For example, we may use a sign in sheet at the front desk to keep track of which patients have arrived. We may call out your name when it is time for you to come back to an exam room. Our employees and independent contractors may have access to our medical records for certain business operations. Our clinic may allow high school, college, or medical school “shadow” students in the clinic and they may be exposed to certain PHI.
   4. Referrals: In order to effectively refer you to another physician, we will have to release certain PHI to that physician to assist that physician in your treatment and to make the necessary appointment.
   5. Consultations: There may be occasions when the Clinic may desire to consult another professional about your treatment to get a second opinion. In those situations, the Clinic will always attempt to maintain your privacy to the extent possible, recognizing that it may not always be an option.
   6. Business Associates: As part of our business operations, we must enter into agreements with third parties to assist us. These third parties can be accountants, computer consultants, transcriptionists, etc. These third parties may have to access certain PHI. Prior to any Business Associates having access to PHI, they will sign an agreement that requires them to have procedures in place to protect the privacy of your PHI.
2. The following are examples of some of the ways the Clinic may use and disclose your PHI based on your opportunity to orally assent or object:
   1. Family Members Involved In Your Care: This clinic may use and disclose PHI to your family members or individuals who are involved in your care when the clinic believes it is necessary. You may inform our Privacy Official in writing if you choose to object to this use or disclosure.
3. The following are examples of some ways the Clinic may use and disclose your PHI without your consent, authorization, or opportunity to assent or object.
   1. Legal Obligations: This clinic will use and disclose PHI when legally required. If this situation occurs, we will notify you and we will limit the PHI to the minimum necessary to comply with the law. Some examples are court orders, subpoenas, reporting suspected abuses or neglect, reporting adverse results to the FDA, reporting exposures to communicable diseases, certain criminal activity and military activity.
   2. Inmates: If you are an inmate, this clinic may use or disclose PHI to the facility and correctional officers when appropriate.
   3. Emergencies: In an emergency treatment situation, our Clinic may use or disclose PHI. Our Clinic’s health care professionals will obtain your consent as soon as practicable following the emergency.
   4. Communication Barrier: If there is a substantial communication barrier, this Clinic may use or disclose PHI for treatment, payment, or health care operations when circumstances would infer consent.
4. The following are examples of some of the ways the Clinic may use and disclose your PHI based on your signing our Clinic’s Authorization form:
   Other uses and disclosures of your PHI that do not fit into one of the above categories shall only be allowed upon your signing one of our Clinic’s specific authorization forms. An example would be if you wanted our Clinic to release your medical records to your employer. You have the right to revoke any authorization, however, the revocation will no be effective to the extent the Clinic has relied upon it.

II. Rights

1. Right to Request a Restriction of Users and Disclosures
   You have the right to notify our Privacy Official in writing that you request a restriction on our use and disclosure of your PHI. Our clinic does not have to grant your request and we can condition treatment on your willingness to consent to our uses and disclosures of your PHI. We will notify you in writing whether we will grant or deny your request. If you request is granted, we may choose, later, to deny continuing the restriction and if so, we will notify you in writing of that decision.
2. Right to Request Confidential Communications
   You have the right to submit in writing a request that all our communications with you concerning your PHI be confidential. These requests must be reasonable, and you must provide reasonable accommodations for us to contact you for payment along with some reasonable method for us to contact you. We cannot ask you the reason for such a request.
3. Right to Inspect and Copy
   You have the right to request in writing to inspect and copy your PHI. There are a few exceptions to this rule. We must approve or deny your request within 30 days and in the case of a denial, provide you an explanation for the reason. We will charge a fee for copying, preparation and postage (if mailed to you), which must be prepaid.
4. Right to Amend
   You have the right to request in writing that we amend your PHI that we created unless the information is accurate and complete. If you make such a written request, we will act on your request and respond in writing within 60 days.
5. Right to Receive an Accounting
   You have the right to request in writing that we provide you with an accounting of our disclosures of your PHI. Standard disclosures are not included in the accounting. Examples of standard disclosures would be disclosures to you, for treatment payment and health care operations. The first accounting in a 12-month period is free. There is a $25.00 charge for the second accounting in the same 12-month period.
6. Right to Receive Copy of Notice
   You have the right to receive a paper copy of our Notice of Privacy Practices. You may pick one up in our front office.
7. Right to File a Complaint
   The law requires us to comply with HIPPA and our Notice of Privacy Practices. If you feel we are not in compliance, you have the right to file an anonymous compliant with our office. We have an anonymous box drop box in our waiting room. You also can file a compliant by notifying our Privacy Official in writing. We will not retaliate in any manner due to a compliant. You also have a right to file a compliant with the Secretary of the Department of Health and Human Services, who is charged with enforcement of this regulation.

III. DISCLOSURE STATEMENTS

1. This clinic intends to use and disclose PHI in the additional following ways, on which treatment is conditioned.
   1. To have you sign in on a sign in sheet
   2. To send out reminders of appointments by phone, mail, or email (this includes postcards)
   3. To send out financial statements and bills
   4. To provide alternative treatment information
   5. To leave messages on answering machines with appointment reminders; and
   6. To contact you at the phone numbers you provide and leave messages to reschedule appointments or to leave lab results
2. The law requires this Clinic have privacy protections for PHI and to give you Notice of its legal responsibilities to individuals.
3. This Clinic must follow the terms and conditions contained in its Notice of Privacy Practices.
4. The Clinic retains the right to make retroactive changes to its Notice of Privacy Practices. This means that if the Clinic changes its Notice of Privacy Practices and thus changes its Privacy Practices and Procedures it can and will apply those changes to PHI it received, obtained, and created prior to those changes if it chooses and states so in the Notice.
5. Any individual who would like a copy of any revised Notices of Privacy Practices shall submit such a request in writing to the Privacy Official whose name is listed on the first page of this Notice.
6. This Notice is effective the 18 th day of September 2002.