Registration Form

Child 1*

First Middle Last

Date of Birth*

Sex*

Resides with*

Who does the child live with?

Biological Parent?*

Race*

Ethnicity*

Parent 1:
First Name*   Last Name*     *         DOB:   *
Street Address*      City*   State*   Zip*
Primary #      XXX-XXX-XXXX*
Cell #      XXX-XXX-XXXX*
Work #      XXX-XXX-XXXX
Email   *
Social Security #   *
Occupation   *

Parent 2:
First Name         Last Name       DOB:
Street Address      City   State   Zip
Primary #      XXX-XXX-XXXX
Cell #      XXX-XXX-XXXX
Work #      XXX-XXX-XXXX
Email
Social Security #
Occupation

Child 2

First Middle Last

Date of Birth

Date

Sex

Resides with?

Biological Parent

Race

Ethnicity

Child 3

Date of Birth

Date

Sex

Resides with?

Biological Parent?

Race

Ethnicity

Child 4

Date of Birth

Date

Sex

Resides with?

Biological Parent?

Race

Ethnicity

Child 5

Date of Birth

Date

Sex

Resides with?

Biological Parent?

Race

Ethnicity

Child 6

Date of Birth

Date

Sex

Resides with?

Biological Parent?

Race

Ethnicity

Subscriber Name*

Policy holder

Insurance Name*

Policy Number*

Subscriber DOB*

Date

Group Number

Effective Date

Date

Guarantee: In consideration of the services provided or to be provided, I, the undersigned, agree to pay the physician(s) for the service rendered to above said patient. Failing to do so, / hereby waive all claims or rights of exemption and agree to pay a reasonable attorney's fee and/or collection fee for the collection of the account if assigned to an attorney

As the parent or legal guardian, / the undersigned authorize the physician to render medical services to the above patient, and to release medical and/or any other information necessary to the third-party payer, at their request, in order to assist in processing any medical claim.

Signature*

Date Signed

Birmingham Pediatric Associates

Thank you for choosing us as your pediatric primary care provider. We are committed to providing your child with quality healthcare. Because some of our patients have had questions regarding patient and insurance financial responsibility for services rendered, we have developed this financial policy. Please feel free to ask us any questions you may have.

INSURANCE: We participate with most insurance plans, except Medicaid, Tricare and ChampVA. If you are not insured by a plan we participate in, payment in full is required at each visit. If you are insured by a plan with which we participate but still need an up-to-date insurance card, payment in full is required at each visit until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please get in touch with your insurance company with any questions you may have regarding your coverage provisions.

PROOF OF INSURANCE: All patients must provide proof of insurance at the time of service. If you fail to promptly provide us with the correct insurance information, you will be responsible for the balance of a claim.

CO-PAYMENTS: All co-payments are due at the time of service via cash, check, or credit card. If a personal check is returned or unpaid from your bank, your account will be charged a returned check fee. $15.00 will be added to account for any copay's not collected at the time of service.

DEDUCTIBLES: If your insurance plan is subject to routine deductibles and co-insurance, we require you to keep a CREDIT CARD ON FILE so we can collect those charges as soon as your insurance carrier assigns the appropriate amount of patient responsibility.

NEWBORNS: Newborns must be added to insurance within 30 days, otherwise they will be considered self-pay.

SELF-PAY: Self-pay patients are expected to pay at the time of service and have a credit card on file.

RETURN CHECK FEE: A $40.00 fee for returned checks will be assessed to your account.

NON-COVERED SERVICES: Please be aware that your insurance company may not cover some of the services your child receives during their visit with us. The providers at Birmingham Pediatric Associates follow the American Academy of Pediatrics recognized standards for well and sick care. If a service is provided to your child but not covered by your insurance, you will be responsible for the resulting charge.

INSURANCE COVERAGE OF WELL VISITS PLUS PROBLEM-BASED VISITS: Well visits may uncover new problems, issues, or illnesses that require additional evaluation or management beyond the typical well visit (ex., ear infections, new onset asthma, anxiety/depression, other new concerns In addition, if your child has very complex chronic healthcare needs, your provider may spend a significant amount of extra time addressing those issues beyond what is typical for a routine well visit. In these situations, your insurance may be charged a problem-based office visit and a well-visit. While well visits may not require a co-pay/deductible, problem-based visits typically do require a co-pay/deductible payment, and, as a result, you will be responsible for that charge.

INSURANCE COVERAGE OF WELL-VISIT SCREENING TESTS: In general, well-visit charges are covered by most insurance companies. However, the cost of screening tests done during a well-visit may or may not be covered. During your child's well visit, your provider will perform various health screenings recommended by the American Academy of Pediatrics Bright Futures Guidelines and considered standard of care in pediatrics. Some insurance companies cover these screenings fully, some apply the cost to the deductible, and others do not cover the cost of the screening tests at all. As a result, you may have responsibility for some of the well-visit charges. Here are some examples of well-visit screening tests that are done in our office: Screening tests include (but are not limited to) the following:

Edinburgh Post-Partum Screening
Ages and Stages Questionnaire (developmental screening)
MCHAT (autism screening)
PSC-17 and PHQ-9 (mental health screening questionnaires)
CHADIS
Hemoglobin (anemia screen)
Lead poisoning screen
Vision screening: Photo-screening (infants, toddlers, young children)
Hearing screening
TB screening questionnaire and, if positive, PPD placement
Brenner FIT questionnaire, Transition readiness questionnaire, and others depending on risk
Urinalysis
CBC

NONPAYMENT: All statement balances are due upon receipt. Please be aware that if a balance remains unpaid, we may need to refer your account to a collection agency, and you and your immediate family members may be discharged from our practice. Should this occur, you will be notified by mail that you will have 30 days to find alternative medical care. During that 30-day period, our providers can only treat you for ongoing and emergency.

AFTER HOURS CALL: There is a $15.00 charge for all calls after hours.

Holiday/Weekend/Afterhours Charge: There will be an "afterhours" charge added to any visit that is not during our normal operating hours. This includes visits after 4:30 PM, weekends, and federal holidays.

MISSED APPOINTMENTS/LATE CANCELLATIONS: We reserve the right to charge $25.00 for missed appointments and canceled same day as appointment. These charges will be your responsibility and will be billed directly to you. Please help us serve you better by keeping your scheduled appointment or canceling it before the day of the scheduled visit. An excessive number of missed appointments will result in discharge from the practice.

RECORD COPYING FEE: If you transfer out of our practice, we will provide you or your new provider with a copy of your records free of charge. Any subsequent requests, legal requests, or other requests will be charged at a rate of

$32.00 per hour or $8.00 for 15 minutes, plus $0.06 cents per page for paper, plus postage if mailed.

$0.00 if transmitted through the patient portal.

$25 fee to have chart pulled from storage.

Thank you for your understanding of our payment policy. Please let us know if you have any questions or concerns.

Name Parent/Guardian Signature*

Print Name*

Date Signed*

Date

One form may be used for all children in the family under age 14; however, all children 14 years of age or older must sign a separate form to allow their information to be disclosed to the contacts listed below.

Date*

Date

Child 1*

First Middle Last

Date of Birth*

Child 2

First Middle Last

Date of Birth

Date

Child 3

Date of Birth

Date

Child 4

Date of Birth

Date

Any physician, staff, employee, or representative of Birmingham Pediatric Associates, Inc. has my permission to discuss and disclose information regarding my account and medical conditions, which may include symptoms, treatments, diagnosis, test results, medications, or any other type of protected health information to facilitate and coordinate my care, treatment, and payment with the following persons:

Name: Contact Name   Relationship: Relationship   Phone: Phone Number
Name: Contact Name   Relationship: Relationship Phone: Phone Number
Name: Contact Name   Relationship: Relationship  Phone: Phone Number
Name: Contact Name   Relationship: Relationship Phone: Phone Number

Any physician, staff, employee or representative of Birmingham Pediatric Associates, Inc. has my permission to discuss and/or disclose protected health information regarding “Blue Form” immunization records and doctor visit excuses for school absence when required by the patient’s school. This information may be disclosed to the school by mail, fax or patient receipt and delivery and will not require any other special authorization beyond this form.

I understand that authorizing the release of my information to the above individual(s) is voluntary and does not affect my access to treatment. I can refuse to sign this form. If I do not sign this form it is invalid and may not be used for contact
information. I can revoke it by writing the
Birmingham Pediatric Associates, Attn: Privacy Officer, 806 St Vincent’s Drive,
Suite 615, Birmingham AL 35205 or by completing a new form at any time.

This authorization will remain in effect until I change or revoke it. I understand that if information is shared with the above individuals it may be subject to re-disclosure by
the individual(s). I have been offered a copy of the Birmingham Pediatric Associates Notice of Privacy Practices and am aware of my responsibilities as well as Birmingham Pediatric Associates legal requirements and limitations as contained in
the Notice of Privacy Practices.

I acknowledge that I have received notification of the privacy practices of Birmingham Pediatric Associates, Inc.
I understand that it is my responsibility to read the Notice of Privacy Practices fully.
I was offered a written copy of the Notice of Privacy Practices on the date signed.
If the signee is not the parent or legal guardian, signee agrees to forward this information to the parent or legal guardian.
If the patient is 13 years of age or younger, the person who brings the patient must sign HERE:

Patients 14 years of age or older MUST sign this form Below Signature*

Name of signer*

Signer relationship to patient(s):*

Not Medicaid Providers