Pediatrics [UPDATED VERSION

Primary Insurance
Insurance Subscriber Name*
(Person that carries the insurance)
Insurance Subscriber Date of Birth*

MonthDayYear
Date
Health Plan*
(Name of insurance)
ID Number*
Group Number
TO CONFIRM THAT WE CAN ACCEPT YOUR INSURACE,

PLEASE UPLOAD A PICTURE OF THE FRONT AND BACK OF YOUR INSURANCE CARD
File Upload*

Cancelof
Secondary Insurance
Insurance Subscriber Name
Date of Birth

MonthDayYear
Date
Health Plan
ID Number
Group Number
Financial Responsibility for Services Rendered by All About Kids Pediatrics
I acknowledge that acceptance of my insurance information is not a guarantee of payment by my health plan until the claim has been processed and paid. I further understand that if my claim is not accepted for payment I am personally responsible for payment of medical services rendered to myself or a member of my family.

I acknowledge that medical billing statements for services rendered by All About Kids Pediatrics will be sent to the person who carries the insurance for the patient/family member.
Signature*

Clear
Date*

MonthDayYear
Date
ASSIGNMENT OF BENEFITS/RELEASE OF INFORMATION
I authorize and direct payment to All About Kids Pediatrics of any insurance benefits including hospital insurance and unemployment compensation disability benefits otherwise payable to or on my behalf for All About Kids Pediatrics, LLC including emergency services, at a rate not to exceed All About Kids Pediatrics, LLC actual charges. I understand that I am financially responsible for charges not paid pursuant to this agreement. I further agree that any credit balance resulting from payment of insurance or other sources may be applied to any other account owed to All About Kids Pediatrics, LLC by me. I also give permission to All About Kids Pediatrics, LLC to release medical information about my child when required by the insurance company or the government agencies responsible for the payment of my child's medical bills.
Signature*

Clear
Date*

MonthDayYear
Date
LATE TO APPOINTMENT POLICY
Please arrive 10 minutes prior to your appointment time. We value your time and strive to see you as close to your appointment time as possible. If you are running late, please call the office to make sure we can hold your appointment.
Signature*

Clear
Date*

MonthDayYear
Date
MISSED APPOINTMENT OR "NO-SHOW" POLICY
It is your responsibility to remember your scheduled appointment. A no-show cancellation fee of $25 may be charged.
Signature*

Clear
Date*

MonthDayYear
Date

Acknowledgement of Receipt of Notice of Privacy Practices
Your name and signature on this sheet indicate that you have been given access to a copy of the Notice of Privacy Practices on the date indicated. If you have any questions regarding the information in the Notice of Privacy Practices, please do not hesitate to contact our office. Also, a copy is posted on our website at www.aakpediatrics.com
Patient's Name*
(First and Last)
Patient's Date of Birth*

MonthDayYear
Date
Parent/Legal Guardian*
(First and Last)
Relationship to Patient*
Signature*

Clear
Date*

MonthDayYear
Date

Vaccine Policy Acknowledgement Form
- All About Kids Pediatrics believes that immunizing our children and young adults is the single most important health-promoting intervention we perform as healthcare providers.
- There is overwhelming evidence that vaccines are safe, effective, and not associated with autism or any other neurodevelopmental conditions.
- We endorse the recommended vaccine schedule as established by the Centers for Disease Control (CDC) and the American Academy of Pediatrics (AAP). There is no accepted alternative.
- We are unable to accept/accomodate children whose parents refuse to vaccinate unless there is a true medical contraindication; it is our duty to keep our vulnerable at risk children safe from exposure to devastating vaccine-preventable diseases.
- We are happy to address and answer all your questions and concerns regarding vaccinating your children and pledge to always provide the most up to date CDC Vaccine Information Sheet (VIS) and discuss possible side effects at each visit for vaccination.
- Please refer to the following sources for further information.
  - American Academy of Pediatrics (www.aap.org/healthtopics/immunizations.cfm
  - Centers for Disease Control and Prevention (www.cdc.gov/vaccines)
  - Immunization Action Coalition (www.immunize.org)
I acknowledge that I have read and understand All About Kids Pediatrics, LLC's Vaccine Policy.
Patient's Name*
(First and Last)
Patient's Date of Birth*

MonthDayYear
Date
Parent/Legal Guardian's Name*
(First and Last)
Relationship to Patient*
Signature*

Clear
Date*

MonthDayYear
Date

REQUEST FOR MEDICAL RECORDS

IF YOU DO NOT HAVE ALL HISTORICAL MEDICAL RECORDS FOR YOUR CHILD(REN), PLEASE LIST PREVIOUS PROVIDER INFORMATION BELOW
Name of Person Requesting Records

First NameLast Name
Relationship to Patient(s)
Phone Number
Patient's Name
(First and Last)
Patient's Date of Birth

MonthDayYear
Date
If you are requesting records for more than one child, list them below.
Patient's Name
(First and Last)
Date of Birth

MonthDayYear
Date
Patient's Name
(First and Last)
Date of Birth

MonthDayYear
Date
Patient's Name
(First and Last)
Date of Birth

MonthDayYear
Date
I, hereby authorize All About Kids Pediatrics, LLC to obtain copies of medical records from:
Name of Doctor and/or Previous Practice
Address
City
State
Phone Number
Fax Number
Reason for release of records:
Transferring Out of PracticeOther
Information to be Released:
Complete medical recordsOther
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

All About Kids Pediatrics

Pediatric Patient Registration Form

Patient Info

Parent/Legal Guardian Info

In case of an emergency, in which a parent/legal guardian cannot be reached, we may need to call someone on your child's behalf. Please list below the name of someone we have your permission to contact if necessary:

CONSENT FOR CONTINUING TREATMENT OF MINOR CHILD

I, the parent/guardian of the minor child listed below, do hereby consent to any diagnosis or treatment rendered under the general or specific instructions of All About Kids Pediatrics.

Primary Insurance

Secondary Insurance

Financial Responsibility for Services Rendered by All About Kids Pediatrics

I acknowledge that medical billing statements for services rendered by All About Kids Pediatrics will be sent to the person who carries the insurance for the patient/family member.

ASSIGNMENT OF BENEFITS/RELEASE OF INFORMATION

LATE TO APPOINTMENT POLICY

MISSED APPOINTMENT OR "NO-SHOW" POLICY

It is your responsibility to remember your scheduled appointment. A no-show cancellation fee of $25 may be charged.

Acknowledgement of Receipt of Notice of Privacy Practices

Vaccine Policy Acknowledgement Form

Health History

Newborn History - if your child is currently under 3 years old at this time

Type of delivery

Surgical History

Medical History

Family History

Medications

REQUEST FOR MEDICAL RECORDS