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Medical History Form
Type N/A if not applicable.
Patient Full Name
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First Name
Last Name
Patient's Preferred name
What is patient's gender?
*
Please Select
Male
Female
N/A
Date of Birth
*
-
Month
-
Day
Year
Date
Race
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American Indian or Alaska Native
Asian
Black/ African American
White
Hispanic
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is both parent's address the SAME as patient's address?
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Yes
No
Parent's Email
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
Parent's Full Name
*
First Name
Last Name
Parent's Date of Birth
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-
Month
-
Day
Year
Date
Parent SSN #
*
Parent's Employer
*
Parent's occupation
*
Second Parent's Full Name
*
First Name
Last Name
Second Parent's Date of Birth
*
-
Month
-
Day
Year
Date
Second Parent's SSN#
*
Second Parent's Employer
*
Second Parent's Occupation
*
Second Phone Number
*
Please enter a valid phone number.
Emergency Contact
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First Name
Last Name
Relation to patient
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Check the symptoms that patient is currently experiencing:
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Cough
Fever
Sore Throat
Congestion
Nausea
Vomiting
Diarrhea
Ear Pain
Urinary
Rash
Injury
Eye pain/red
Other
List any medical history for patient. (autism, heart defects, asthma, surgeries etc.)
*
Are you currently taking any medication?
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Yes
No
Please list them.
*
Do you have any medication allergies?
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Yes
No
Not Sure
Please list them.
*
Requested Pharmacy
*
Pharmacy Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Care Provider Name
*
Primary Care Provider's OFFICE NAME
*
Do you give permission for medical records to be sent to PCP?
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Yes
No
Insurance Company/Plan
*
Member ID number
*
List below who you authorize to bring patient for visits. Name & relation
*
I agree that above information is accurate and will be used for patient's medical record.
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CONSENT FOR CARE/TREATMENT
I, the undersigned, for myself or a minor child or another person for whom I have authority to sign, hereby consent to medical care and treatment, as ordered by a provider, while such medical care and treatment is provided through Kid Care Pediatric Urgent Care, on an out patient office visit basis. This consent includes my consent for all medical services rendered under the general or specific instructions of a provider; including treatment by a nurse practitioner, and other health care providers or the designee sunder the direction of a physician, as deemed reasonable and necessary. I agree and acknowledge that Kid Care Pediatric Urgent Care is not liable for the actions or omissions of, or the instructions given by the physician/providers who treat me while I am a patient. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the result of treatments or examinations at kid care pediatric urgentcare. Telemedicine I understand that telemedicine (defined as the use of medical information exchanged from one site to another via electronic communications for the health of the patient, including consultative, diagnostic, and treatment services) may be employed to facilitate my medical care period all electronic transmissions of data will be restricted to authorized participants in compliance with the Federal Health Insurance Portability and Accountability Act (HIPAA) and applicable state privacy laws. To the Patient You have the right to discuss the treatment plan with your provider about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your health care provider, we encourage you to ask questions period by signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or another satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.
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HIPAA
HIPAAI understand that as part of my health care, Kid Care Pediatric Urgent Care originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnosis, and any plans for future care or treatment, I understand that this information serves as: A basis for planning my care. A means of communication among the many health professionals who contribute to my care A source of information for applying my diagnosis and surgical information to my bill. A means by which a third-party payer can verify the services billed were actually provided. A means to send statement and reminder cards to the address given at time of registration. A tool for routine health care operations such as assessing quality and reviewing the competence of healthcare professionals. With this consent, Kid Care Pediatric Urgent Care may call home or other alternative locations and leave a message on voicemail or in person in reference to any items that may assist the practice in carrying out treatment, payment, and healthcare operations. (TPO).The complete notice of information practices is available in this office for review during normal business hours of operation. I understand and have been given an opportunity to read the notice of information practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:The right to review the notice prior to signing this consent,The right to object to the use of my health information for directory purposes, andThe right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations.I understand that Kid Care Pediatric Urgent Care is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by section 164.506 of the Code of Federal Regulations. I further understand that Kid Care Pediatric Urgent Care reserves the right to change their notice and practices prior to implementation, in accordance with section 164. 20 of the Code of Federal Regulations. Should Kid Care Pediatric Urgent Care change their notice, they will send a copy of any revised notice to the address t have provided. I understand that as part of this organization, treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via phone and fax. By my signature, I fully understand and accept the terms of this consent.
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FINANCIAL POLICY
Patients With Insurance:We will file your claim with insurance, but we can only file if you present proof of coverage and a valid Picture ID.To control billing costs, we require a pre-authorized credit card or debit card to cover any balance not paid by your insurance. If you provide your e-mail address, we will inform you seven business days prior to charging the balance to your credit card. We always collect co-payment at the time of service for any portion not covered by insurance. If a balance remains for any reason after your insurance company processes the claim, you agree to make remittance to us upon receipt of notice from your carrier. I understand I am responsible for payment within 30 days of service from those items deemed not covered by my insurance company. Patients without insurance If you do not have insurance, we will collect payment in full directly from you prior to services being delivered. We do not accept personal/ handwritten checks for payment. Account Policy You expressly consent and agree that, in order to discuss or service your account or to collect amounts you may owe, Kid Care Pediatric Urgent Care, and it affiliates, employees, and any third-party debt collection agency associated there with make contact you by telephone at any telephone number associated with the accounts, including wireless telephone numbers, which could result in charges to you. You expressly consent and agree that we may also contact you by sending text messages, emails, using any e-mail address you provide to us, or by prerecorded or artificial voice or voice messages, automatic dialing methods, systems, or devices, and prerecorded or artificial voice prompts at any telephone number associated with the accounts, including wireless or mobile telephone numbers, regardless of whether you incur charges as a result. I understand that the payments as described above is due at the time of service. I have read the above financial and account policy and agree to make payment as described above. No credit is extended.We are happy to provide a copy of your signed Financial Policy with request.
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