Write N/A for anything that is not applicable

Patient’s Full Name: *

Age: *

Sex:*

MF

D.O.B: *

MM/DD/YYYY

Address: *

City and State: *

Zip Code: *

Primary Phone: *

Secondary Phone

Email: *

Mother’s Name:*

Mother’s Date of Birth: *

MM/DD/YYYY

Mother’s Address: *

City and State: *

Zip Code: *

Father’s Name: *

Father’s Date of Birth:

MM/DD/YYYY

Father’s Address: *

City and State: *

Zip Code: *

Emergency Contact #1: *

Relationship: *

Phone Number: *

Emergency Contact #2: *

Relationship: *

Phone Number: *

Referral Information: How did you know about us?*

Insurance Information:

Primary Insurance: *

ID #: *

Group#: *

Effective Date: *

MM/DD/YYYY

Card Holder Name: *

Secondary Insurance:

ID #:

Group#:

Effective Date:

MM/DD/YYYY

Card Holder Name:

Pharmacy:

Name of pharmacy: *

Pharmacy telephone: *

Please give secretary your insurance card. We ask all patients to show their insurance card or membership card so that we may make copies of them.

PAYMENT AUTHORIZATION

I hereby authorize Passaic Pediatrics, PA to furnish information concerning my present illness. I direct the insurer to pay, without equivocation, directly to the physician, all benefits due him as a result of his claim. Although covered by insurance, I am aware that I am personally responsible for all charges. A photo static copy of this authorization will be as valid as the original.

your signature or signature of legal guardian*

Date*

MM/DD/YYYY

Patient’s Name: *

Date*

MM/DD/YYYY

PRIVACY NOTICE

Your Privacy Is Important

Passaic Pediatrics understands your privacy is important. You have received this notice in accordance with applicable state and federal laws and because you are current or potential patient. This notice will help you understand what types of non-public personal information (information about you that is not publicly available) we may collect, how we use it and how we protect your privacy.

Passaic Pediatrics Privacy Policy Highlights

We collect non-public personal information to process and administer our patient’s business.
We have policies and procedures in place to protect non-public personal information about our patients or their families.
We do not sell non-public personal information about our patients or their families to third parties, i.e., companies or individuals that are not affiliated with us.
We do not disclose any non-public personal information about our patients or their families to anyone, except as permitted by law.
We disclose your private health information routinely to insurance companies, other providers, and others for purposes of treatment, payment and healthcare operations.
For all other purposes, we will either obtain your authorization or remove all information that could identify you as an individual.
Our privacy Policy applies to both current and former patients.

Questions and Answers

What types of non-public personal information does Passaic Pediatrics collect?

Passaic Pediatrics’ employees, representatives, agents and selected third parties may collect non-public personal information about our patients or their families, including:

Information provided to us, such as on applications or other forms.
Information about transactions with affiliates, our third parties or us.
Information from others, such as credit reporting agencies, employers and federal and state agencies.

The types of non-public personal information Passaic Pediatrics collects vary according to the products or services provided and may include, for example: Account balances, insurance premiums, marital status and health history.

What does Passaic Pediatrics do to protect non-public personal information?

We restrict access to non-public personal information to those employees, agents, representatives or third parties who need to know the information to provide products and services to our patients or their families.

We have policies and procedures that give direction to our employees, and agents and representatives acting on our behalf, regarding how to protect and use non-public personal information. We maintain physical, electronic and procedural safeguards to protect non-public personal information.

With whom does Passaic Pediatrics share non-public personal information, and why?

We do not share non-public personal information about our patients or their families with anyone, including other affiliated companies or third parties, except as permitted by law.

We may disclose, as allowed by law, all types of non-public personal information we collect when needed, to affiliated companies, agent’s employees, representatives and third-parties that market our services and products and administer and service customer accounts on our behalf. Examples of the types of companies and individuals to whom we may disclose non-public personal information include attorneys, trustees, third-party administrators, insurance agents, insurance companies, insurance support organizations, credit reporting agencies, registered broker/dealers, auditors and regulators.

We do not share personally identifiable health information unless the customer or the applicable law authorizes further sharing.

Does Passaic Pediatrics’ Privacy Policy apply to its agents and representatives?

Passaic Pediatrics’ Privacy Policy applies, to the extend required by law, to its agents and representatives when they are acting on behalf of Passaic Pediatrics.

Please Note: There may be instances when these same agents and representatives may not be acting on behalf of Passaic Pediatrics in which case they may collect non-public personal information on their own behalf or on behalf of another. In these instances, Passaic Pediatrics’ Privacy Policy would not apply.

Will Passaic Pediatrics’ Policy change?

Passaic Pediatrics reserves the right to change any of its privacy policies and related procedures at any time, in accordance with applicable federal and state laws. You will receive appropriate if our Privacy Policy changes.

I hereby acknowledge that I have been presented with a copy of Passaic Pediatrics’ Notice of Privacy Practices.

Your signature or signature of legal guardian*

Date*

MM/DD/YYYY