Continuum-New-Patient-04-30-2024

New Patient Registration Form
Today's Date*

MonthDayYear
Date
Patient's Name*

First NameLast Name
Patient's Date of Birth (DOB)*

MonthDayYear
Date
Patient's Nickname
Gender*

MaleFemale
Parent/Guardian Full Name*

First NameLast Name
Date of Birth (DOB)*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell/Home Number*
Please enter a valid phone number.
Work Number*
Please enter a valid phone number.
Email*
example@example.com
Employer*
Parent/Guardian Name

First NameLast Name
Date of Birth (DOB)

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell/Home Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Email
example@example.com
Employer
NOTE: If parents are divorced or living separately, please provide copies of custody papers at FIRST visit.
Who does patient life with?*

MotherFatherBothGuardian
Primary Insurance Company*
ID Number*
Group Number*
Insurance Phone Number*
Please enter a valid phone number.
Subscriber's Name*
Subscriber's DOB*

MonthDayYear
Date
Subscriber's Relationship to Patient*
Secondary Insurance Company
ID Number
Group Number
Insurance Phone Number
Please enter a valid phone number.
Subscriber's Name
Subscriber DOB

MonthDayYear
Date
Subscriber's Relationship to Patient
Preferred Pharmacy*
Pharmacy Phone Number*
Please enter a valid phone number.
Medicaid Wiaver

Continuum Pediatrics will NOT ACCEPT Medicaid of Texas as primary or secondary insurance.
I (patient's guardian)* have read, understand, and agree to the above policy by Continuum Pediatrics. I will be responsible for any non-covered services not covered by my health insurance plan(s).

This waiver is valid for all dates of service. All patients must complete and sign this form even if you have no intention of using Medicaid as a form of payment.
Parent/Guardian's Signature*

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Relationship to Patient*
Date*

MonthDayYear
Date

Consent for Treatment Authorization
Patient's Name*

First NameLast Name
Date of Birth (DOB)*

MonthDayYear
Date
Parent/Guardian's Name*

First NameLast Name
I hereby authorize the following person(s) to seek medical care and make decision in relation to advice rendered at Continuum Pediatrics and/or it's employees in my absence.
Printed Name blanks: Relationship to Patient blank .
Printed Name blanks: Relationship to Patient blank .
This authorization shall remain in affect from today's date for a period of one year, sooner if revoked in writing or if any changes.
Disclosure to Friends and/or Family Members

If you would like the Practice to share protected health information about your care with your friends or family members, please list the individual(s) who may receive your information below.
Name blanks Phone Number blank .
Name blanks Phone Number blank .
Name blanks Phone Number blank .
Assignment of Benefits
Financial Responsibility

All professional services rendered are charged to the patient and are due at the time of service unless other arrangements have been made in advance with our billing office. Necessary forms will be completed to file for insurance carrier payments. If the child has multiple carriers it is solely the parent/guardian’s responsibility to inform this office. Should any claims be denied of payment for this reason and our office has not been aware, payment of all denied claims will become the responsibility of the parent/ guardian. There may be times when a “well” visit will be changed to a “sick” visit based on diagnosis during your evaluation by the physician. Your insurance company may require you to pay additional coinsurance or fees at the time of service. Please check with your insurance carrier about your specific benefits.
Assignment of Benefits

I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier to issue payment checks directly to Continuum Pediatrics, a division of Texas Digestive Disease Consultants- GI Alliance, for medical services rendered to myself and or my dependents regardless of my insurance benefits, if any. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY THE INSURANCE.
Authorization to Release Information

I hereby authorize Continuum Pediatrics to 1) release any information necessary to insurance carriers regarding my illness and treatments (2) process insurance claims generated in the course of examination and treatments; (3) allow a photocopy of my signature to be used in the process of insurance claims for the period of a lifetime. This order will remain in effect until revoked by me in writing. I have requested medical services from on behalf of myself and or my dependents, and I understand that by making this request, I BECOME FULLY FINANCIALLY REPONSIBLE FOR ANY AND ALL CHARGES INCURRED IN THE COURSE OF THE TREATMENT AUTHORIZED. I FURTHER UNDERSTAND THAT FEES ARE DUE AND PAYABLE AT THE TIME THAT SERVICES ARE RENDERED, AND I AGREE TO PAY ALL SUCH CHARGES INCURRED IN FULL IMMEDIATELY UPON PRESENTATION OF THE APPROPRIATE STATEMENT. A photocopy of this assignment is to be considered as valid as the original.
Parent/Guardian's Signature*

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Relationship to Patient*
Date*

MonthDayYear
Date

PLEASE READ YOU CAN DOWNLOAD A COPY FOR YOUR RECORDS
Vaccine Policy
- We firmly believe in the effectiveness of vaccines to prevent serious illness and to save lives. w We firmly believe in the safety of our vaccines.
- We firmly believe that all children and young adults should receive all of the recommended vaccines according to the schedule published by the Centers for Disease Control and Prevention and the American Academy of Pediatrics.
- We firmly believe, based on all available literature, evidence, and current studies, that vaccines DO NOT cause autism or other developmental disabilities. We firmly believe that thimerosal, a preservative that has been in vaccines for decades and remains in some vaccines, does not cause autism or other developmental disabilities.
- We firmly believe that vaccinating children and young adults may be the single most important health-promoting intervention we perform as health care providers, and that you can perform as parents/caregivers. The recommended vaccines and their schedule given are the results of years and years of scientific study and data gathering on millions of children by thousands of our brightest scientists and physicians.
These things being said, we recognize that there has always been and will likely always be controversy surrounding vaccination. Indeed, Benjamin Franklin, persuaded by his brother, was opposed to smallpox vaccine until scientific data convinced him otherwise. Tragically, he had delayed inoculating his favorite son Franky, who contracted smallpox and died at the age of 4, leaving Ben with a lifetime of guilt and remorse. Quoting Mr. Franklin’s autobiography:

“In 1736, I lost one of my sons, a fine boy of four years old, by the smallpox . . . I long regretted bitterly, and still regret that I had not given it to him by inoculation. This I mention for the sake of parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it, my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen.”

The vaccine campaign is truly a victim of its own success. It is precisely because vaccines are so effective at preventing illness that we are even dis- cussing whether or not they should be given. Because of vaccines, many of you have never seen a child with polio, tetanus, whooping cough, bacterial meningitis, or even chickenpox, or known a friend or family member whose child died of one of these diseases. Such success can make us complacent or even lazy about vaccinating. But such an attitude, if it becomes widespread, can only lead to tragic results.

After publication of an unfounded accusation (later retracted) that MMR vaccine caused autism in 1998, many people in Europe chose not to vaccinate their children. As a result of under immunization, there were large outbreaks of measles, with several deaths from complications of the disease. In 2010 there were more than 3000 cases of whooping cough in California, with nine deaths in children less than six months of age. Again, many of those who contracted the illness (and then passed it on to the infants, who were too young to have been fully vaccinated) had made a conscious decision not to vaccinate.

Furthermore, by not vaccinating your child you are taking selfish advantage of thousands of others who do vaccinate their children, which decreases the likelihood that your child will contract one of these diseases. We feel such an attitude to be self-centered and unacceptable.

We are making you aware of these facts not to scare you or coerce you, but to emphasize the importance of vaccinating your child. We recognize that the choice may be a very emotional one for some parents. We will do everything we can to convince you that vaccinating according to the schedule is the right thing to do. However, should you have doubts, please discuss these with our office in advance of your visit. Please be advised, that delaying or “breaking up the vaccines” to give one or two at a time over two or more visits goes against expert recommendations, and can put your child at risk for serious illness (or even death) and goes against our medical advice as providers at Continuum Pediatrics.

All patients in the practice are required to receive a minimum of DTaP, Hib, polio, and pneumococcal vaccines by three months of age, all AAP-recommended immunizations by two years of age, and meningococcal vaccine and booster doses of Tdap and varicella vaccines by age 12 years.

Finally, if you should absolutely refuse to vaccinate according to the CDC and AAP guidelines, despite all our efforts, we will ask you to find another health care provider who shares your views. We do not keep a list of such providers, nor would we recommend any such physician. Please recognize that by not vaccinating you are putting your child at unnecessary risk for life-threatening illness and disability, and even death.

As medical professionals, we feel very strongly that vaccinating children on schedule with currently available vaccines is absolutely the right thing to do for all children and young adults.

Thank you for your time in reading this policy, and please feel free to discuss any questions or concerns you may have about vaccines with any one of us.

From Drs. Kathryn Mandal, Krystyna Wesp, Likhitha Reddy, Cynthia Giovannetti, and the Staff of Continuum Pediatrics.

Immunization Action Coalition • 1573 Selby Ave. • St. Paul, MN 55104 • (651)647-9009 • www.immunize.org • www.vaccineinformation.org

Office Policies
Vaccine Policy:*

I have read the enclosed vaccine policy and intend to vaccinate my child according to the most current guidelines set forth by the American Academy of Pediatrics and the US Centers for Disease Control.
After Hours Calls:*

Our office hours are Monday through Friday 8:00am to 5:00pm. We make every effort to return patient calls promptly, usually by the end of the business day. After hour calls are defined as calls received after 5:00pm Monday-Friday and all weekends or holidays. These calls will accrue a $35.00 AFTER HOURS FEE applied to your account. This fee cannot be billed to your insurance company.
No Show Policy:*

We ask you to be considerate of the medical needs of others and call our office promptly within 24 hours of your appointment if you are unable to make your appointment time. This allows us to make your appointment available to another patient who needs medical attention. If you do not arrive for your appointment, or fail to cancel prior to 24 hours before your appointment time, there will be a $50.00 NO SHOW FEE applied to your account that will need to be paid in full by the next scheduled appointment time. This fee cannot be billed to your insurance company. You may be reminded of your upcoming appointment by portal reminder, text, or phone call. Please understand that these reminders regarding your appointment are a COURTESY only, any disputes regarding no shows because of a courtesy call or text “not received” will NOT be waived. You are ultimately responsible. The doctors make every effort to be respectful of our patients’ time and to see our patients on time. Please be aware that if you arrive 10 MINUTES after your scheduled appointment time, you may be asked to reschedule.
Letters/Completion of Forms:*

Please bring any forms that require a doctor’s approval to your appointment. Any requests for forms to be completed after an appointment will accrue a fee. This fee will be applied to your account and will not be covered by insurance. Please give our office 48 hours to complete any forms. Any letter that you request the physician to write also will incur a fee. This fee cannot be billed to your insurance company. Please contact the office staff for a list of fees for commonly requested forms.
Consent for Photography

I hereby consent Continuum Pediatrics to photograph my child and an adult caregiver. The purpose is to document the identity of the patient and caregiver in the medical and billing records for the purpose of clinical care as well as collection of payments.
Patient's Full Name*
Date*

MonthDayYear
Date
Parent's Name*
Parent/Guardian's Signature*

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HIPAA NOTICE OF PRIVACY PRACTICES

Effective March 1, 2023
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.
Scope of Notice

This Notice of Privacy Practices (“Notice”) applies to all protected health information (“PHI”) about you held or transmitted by Continuum Pediatrics,Texas Digestive Disease Consultants, PLLC d/b/a GI Alliance and each of its subsidiaries and affiliates who are under common control and/or common ownership that are subject to HIPAA (as defined below) and are designated for HIPAA purposes as an affiliated covered entity (collectively, “we” or “our Practice”).

PHI is any individually identifiable health information about your past, present or future physical or mental health or condition, the provision of healthcare to you, or your payment for healthcare. PHI may include information about your condition or treatment, diagnostic tests and images, and related health information.

Our Responsibilities

Our Practice is dedicated to maintaining the privacy of your PHI. Our Practice is required by the Health Insurance Portability and Accountability Act ("HIPAA") to maintain the privacy of your PHI and to provide you with notice of our legal duties and privacy practices with respect to your PHI. We are also required by law to notify affected individuals following a breach of unsecured PHI.

Our Practice must abide by the terms of this Notice while it is in effect. This Notice will remain in effect until our Practice replaces it. We reserve the right to change the terms of this Notice at any time, provided the changes comply with applicable law. If our Practice changes the terms of this Notice, the new terms will apply to all PHI we maintain, including PHI that was created or received before such changes were made. If our Practice changes this Notice, we will post the new Notice on our website and will provide copies upon request.

Uses and Disclosure of PHI that Do Not Require an Authorization

The following categories describe the different ways that our Practice may use and disclose your PHI without your authorization. Not every use and disclosure within a category will be listed. Your PHI may be stored in paper, electronic or other form and may be disclosed electronically or by other methods.

Treatment. Our Practice may use and disclose your PHI for treatment purposes. For example, we may disclose PHI to another healthcare provider to whom we refer you. Moreover, we may use and disclose your PHI electronically, such as by providing you care via telehealth (which involves the use of electronic communications via live two-way audio or video) or by communicating with you through our patient portal (if you choose to access the portal).

Payment. Our Practice may use and disclose your PHI to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections and claims management. These activities also include determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, our Practice may send claims to your health insurance provider containing certain PHI.

Healthcare Operations. Our Practice may use and disclose your PHI for healthcare operations purposes. Healthcare operations include quality assessment and improvement activities, arranging for legal services, conducting training programs, reviewing the competence and qualifications of healthcare professionals, licensing activities, and sending you information about our healthrelated products and services, possible treatment options or alternatives that may interest you, or appointment reminders. We may make incidental disclosures of limited PHI, such as by mailing statements to you with your name on the envelope.

Business Associates. Our Practice may disclose your PHI to third parties who provide services to our Practice or on our Practice’s behalf, known as Business Associates. Our Practice requires our Business Associates to enter an agreement to safeguard your PHI and otherwise protect your privacy as required by law.

Electronic Data Exchanges. Consistent with applicable law, we may send you text messages, emails or other electronic communications for treatment, payment, healthcare operations and other permitted purposes. Our Practice may participate in one or more Health Information Exchanges (HIEs) and may electronically share your PHI for treatment, payment, healthcare operations and other permitted purposes with other participants in the HIE. HIEs allow your healthcare providers to efficiently access and use your PHI as necessary for treatment and other lawful purposes.

Individuals Involved in Your Care or Payment for Your Care/Personal Representatives. Our Practice may disclose your PHI to your family or friends, or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, if a person has the authority by law to make healthcare decisions for you, we may disclose information about you to such patient representative and treat that patient representative the same way we would treat you with respect to your PHI. We may also disclose your PHI to a public or private entity authorized by law to assist in disaster relief efforts to notify, or assist in notifying, a family member or personal representative about your location, general condition, or death.

Required by Law. Our Practice may use or disclose your PHI when we are required to do so by law. For example, we may disclose PHI about you to the U.S. Department of Health and Human Services if it requests such information to determine that we are complying with federal privacy law.

Public Health Activities. Our Practice may disclose your PHI to public health authorities or other governmental authorities for public health purposes including preventing and controlling disease, reporting child abuse or neglect and reporting to the Food and Drug Administration regarding the quality, safety and effectiveness of a regulated product or activity. Our Practice may, in certain circumstances, disclose PHI to persons who have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition as necessary in the conduct of a public health intervention or investigation.

Health Oversight Activities. Our Practice may disclose your PHI to a health oversight agency for authorized activities such as audits, investigations, inspections, licensing and disciplinary actions.

Abuse, Neglect or Domestic Violence. If our Practice reasonably believes you are a victim of abuse, neglect, or domestic violence, we may disclose your PHI to a government authority, including a social service protective agency, authorized by law to receive reports of abuse, neglect or domestic violence.

Judicial and Administrative Proceedings. Our Practice may disclose your PHI in response to an order from a court or administrative agency. We may also disclose your PHI in response to a subpoena, discovery request or other lawful process instituted by someone involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. Our Practice may disclose your PHI for law enforcement purposes as permitted by HIPAA.

Coroners, Medical Examiners and Funeral Directors. Our Practice may disclose your PHI to coroners, medical examiners and/or funeral directors for purposes such as identification, determining the cause of death, and fulfilling duties relating to deceased individuals.

Research. Our Practice may use or disclose your PHI for research when permitted by law, including when an institutional review board or privacy board has reviewed the research proposal and established a process to ensure the privacy of the requested information and approved the research.

Serious Threat to Health or Safety. Our Practice may use or disclose PHI when permitted by applicable law to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

Worker’s Compensation. Our Practice may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.

Specialized Government Functions. Our Practice may use and disclose PHI for specialized government functions, including military and veterans’ activities, national security and intelligence activities, and to correctional institutions.

Organ Donation. Our Practice may use and disclose your PHI to entities involved in procuring, banking, and transplanting organs, eyes and tissues to assist with donation or transplantation.

Limited Data and De-identified Data. Our Practice may remove most information that identifies you from a set of data and use and disclose this data set for research, public health and healthcare operations, provided the recipients of the data set agree to keep it confidential. We may also de-identify your PHI and use and disclose the de-identified information for purposes permitted by law.

Use and Disclosure of PHI Pursuant to an Authorization

In any other situation not described in this Notice, our Practice will ask for your written authorization before using or disclosing information about you, in accordance with applicable law. Most uses and disclosures of PHI for marketing purposes and disclosures that constitute a sale of PHI will be made only with your written authorization. You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI for the purpose previously authorized, except to the extent that we have already taken action in reliance on the authorization.

Your Rights Regarding Your PHI

You have the following rights regarding the PHI maintained by our Practice. If you have given another individual a medical power of attorney, if another individual is appointed as your legal guardian or if another individual is authorized by law to make healthcare decisions for you (such as your custodial parent) (known as a “personal representative”), that individual may exercise any of the rights listed below for you.

Confidential Communications. You have the right to receive confidential communications of your PHI. You may request that our Practice communicate with you through alternate means or at an alternate location, and our Practice will accommodate your reasonable requests. You must submit your request in writing to our Practice. If we are unable to contact you using the ways or locations you have requested, we may contact you using the information we have.

Restrictions. You have the right to request restrictions on certain uses and disclosures of PHI for treatment, payment or healthcare operations. You also have the right to request that our Practice restrict its disclosures of PHI to only certain individuals involved in your care or the payment of your care. You may also request to opt out of participation in HIEs. You must submit your request in writing to our Practice. Our Practice is not required to comply with your request, except we are required to agree if your request is to restrict disclosures to a health plan for purposes of carrying out payment or healthcare operations, and the information pertains solely to a healthcare item or service for which you, or a person on your behalf (other than the health plan), has paid us outof-pocket in full. If our Practice agrees to comply with your request, we will be bound by such agreement, except when otherwise required by law or in the event of an emergency.

Access. You have the right to inspect and obtain copies of your PHI that we maintain and to direct us to send your PHI stored in an electronic record to another person designated by you, with limited exceptions. This right applies to PHI used to make decisions about you or payment for your care, subject to limited exceptions provided by law. You must submit your request in writing to our Practice using the information provided at the end of this Notice. In most cases, we will provide access to you or the person you designate to get access within 30 days of your request or, if applicable, any shorter time period required by law.

Our Practice may deny your request to inspect and/or obtain a copy of your PHI in certain limited circumstances, such as if we reasonably conclude that it would be detrimental to you. If we deny your request, we will inform you of the reason for the denial, and, in most cases, you may request a review of the denial. If you request PHI that we maintain on paper, we may provide photocopies. If you request PHI that we maintain electronically, you have the right to an electronic copy. We will use the form and format you request if readily producible.

We may impose a reasonable cost-based fee for the costs of copying, mailing, labor and supplies associated with your request.

Amendment. You have a right to request that our Practice amend your PHI if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is maintained by our Practice. You must submit your request in writing to our Practice using theinformation provided at the end of this Notice and provide a reason to support the requested amendment. Our Practice may, under certain circumstances, deny your request by sending you a written notice of denial. If our Practice denies your request, you will be permitted to submit a statement of disagreement for inclusion in your records.

Accounting of Disclosures. You have a right to receive an accounting of certain disclosures our Practice has made of your PHI. This right does not include disclosures made pursuant to an authorization and certain other disclosures. You must submit your request in writing to our Practice using the information provided at the end of this Notice, and you must specify the time period involved (which must be for a period of time less than six years from the date of your request). Your first accounting within a period of 12 months will be free of charge. However, our Practice may charge you a reasonable cost-based fee for the costs involved in fulfilling any additional request made within the same 12-month period. Our Practice will inform you of such costs in advance so that you may withdraw or modify your request to save costs.

Paper Copy of this Notice. You have the right to obtain a paper copy of this Notice from our Practice at any time upon request, even if you have agreed to receive this Notice electronically. To obtain a paper copy of this notice, please email complianceGIA@gialliance.com or ask for a copy at one of our offices.

Complaints

You may complain to our Practice and/or to the Secretary of the Department of Health and Human Services (“the Secretary”) if you believe that your privacy rights have been violated. You may submit complaints to our Practice by contacting our Practice’s Privacy Officer at complianceGIA@gialliance.com or by calling our Privacy Officer at 1-877-373-1630.

Our Practice will not retaliate against you if you file a complaint with our Privacy Officer or the Secretary. You may file a complaint with the Secretary by contacting:

U.S. Department of Health and Human Services Office for Civil Rights 200 Independence Avenue, S.W. Washington, D.C. 20201 Phone: 1-877-696-6775; or www.hhs.gov/ocr/privacy/hipaa/complaints/

Contact Information

For more information about your privacy rights, please contact our Privacy Officer at complianceGIA@gialliance.com or1-877-373-1630.

HIPAA NOPP Effective Date 03.01.2023

New Patient Health History
Patient's Name*

First NameLast Name
Date of Birth (DOB)*

MonthDayYear
Date
Birth History
Was your child born?*

PrematureNot Premature
If premature birth: How many weeks early blanks ? Was there a NICU stay? Yes/No
Child's weight at birth:*
Any problems after birth?*
Was your child born:*

VaginalC-Section
Does your child have chronic medical problems (Ex. allergies, ADHD, autism)?*
Does your child take medication on a regular basis? If so, please list below*
Does your child have allergies to medications*
Has your child ever been hospitalized overnight? (not ER visits)*
Has your child had any surgeries? If so, please list below*
Tell us about your family:
Patient's mother's DOB Date* : Medical problems blank.
Patient's father's DOB Date* : Medical problems blank.
Patient's Brother(s) Name(s), DOB, and medical problems:
Patient's Sister(s) Name(s), DOB, and medical problems:
Do you have any forms you would like the doctor to complete?*

YesNo
Please list any and all concerns you would like to discuss with the doctor during your appointment.*
Should be Empty:

New Patient Registration Form

NOTE: If parents are divorced or living separately, please provide copies of custody papers at FIRST visit.

Medicaid Wiaver

Consent for Treatment Authorization

Disclosure to Friends and/or Family Members

Assignment of Benefits

Financial Responsibility

Assignment of Benefits

Authorization to Release Information

PLEASE READ YOU CAN DOWNLOAD A COPY FOR YOUR RECORDS

Office Policies

HIPAA NOTICE OF PRIVACY PRACTICES

New Patient Health History

Birth History

Tell us about your family: