Current Patient Update

Welcome to Alzein Pediatrics!
PATIENT Information
Today's Date:*

MonthDayYear
Patient's Birth Date:*

MonthDayYear
Patient's Name:*

FirstMILast
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender:
Does patient currently have siblings at Alzein Pediatrics?*
Emergency Contact:*
Relationship to Patient:*
Mother's Name*

First NameLast Name
Mother's Phone Number*

Area CodePhone Number
Mother's Email*
example@example.com
Mother's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Occupation
Father's Name

First NameLast Name
Father's Phone Number

Area CodePhone Number
Father's Email
example@example.com
Father's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Occupation
Emergency Contact Phone Number:*

Area CodePhone Number
Email(for access to your patient portal):*
Help us provide better care by answering these questions.
Languages Spoken at Home:*

ArabicEnglishIndian DialectPolishSpanishOther

INSURANCE INFORMATION
Please remember that copays are due at time of service. Thank you!
Primary Insurance Company Name:*
Cardholder's Name:*
Cardholder's Phone Number:*

Area CodePhone Number
Insurance ID#:*
Group#:*

In Case of Divorce
1) In case of divorce, we request a copy of the court order regarding patient’s custody.

2) In case of divorce, the parent who brings the patient into the office for medical treatment will be responsible for payment at time of service.

Pharmacy Information
Please identify your preferred pharmacy. When your child needs prescription medication, we'll call the prescription into this pharmacy.
Pharmacy Name:*
Pharmacy Phone Number*

Area CodePhone Number
I authorize the treatment of my child by a Provider employed by Alzein Pediatrics. I authorize the release of any information concerning my (or my child’s) healthcare, advice, and treatment provided for the purpose of evaluation and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to the Provider, realizing I am responsible to pay non-covered services. I am also aware of the payment and fee policies of Alzein Pediatrics.
Signature of Parent (or patient if over 18)*
Date:*

MonthDayYear
Date
Consent by Proxy Pediatrics Care

For families who are patients of Alzein Medical Ltd DBA Alzein Pediatrics.
I (we) appoint the individuals(s) listed below as my (our) proxy decision maker for consenting to medical care for my (our) child blanks , date of birth blank.
I (we) have the legal right to delegate consent to the proxy decision maker, who is an adult and legally and medically competent to exercise the authority so delegated if I (we) cannot be contacted. Be advised that protected patient health information may be shared with the proxy to facilitate informed decision making.
Effective dates from blanks to blank .
Proxy Information
Name blanksDate of birth blank Relation to child
blank
Name blanksDate of birth blank Relation to child
blank
Name blanksDate of birth blank Relation to child
blank
Name blanksDate of birth blank Relation to child
blank
Limitations
Identify any limitations on the kinds of medical services for which this consent by proxy is given. If none, state “none”.
Parent Information

I (we) have the legal right to delegate consent to treat the proxy decision maker listed above, who is an adult and legally and medically competent to exercise the authority so delegated if I (we) cannot be contacted. I understand that protected patient health information may be shared with the proxy to facilitate informed decision making.
Parent Name
Primary Phone
Secondary Phone
Parent Name
Primary Phone
Secondary Phone
Signature of Parent/Legal Guardian

Clear
Date

MonthDayYear
Date
Signature of Parent/Legal Guardian

Clear
Date

MonthDayYear
Date
HIPAA Acknowledgement of Notice of Privacy Practices
Alzein Pediatric Associates is required by law to maintain the privacy of and provide patients and their guardians with access to the Notice of our legal duties and privacy practices with respect to protected health information.
Name of Patient:*

First NameMILast Name
Patient's DOB:*

MonthDayYear
Date
I hereby acknowledge that I have reviewed the Hipaa Notice of Privacy document and understand that I may obtain a copy for my records upon request.
Signature of Patient/Legal Representative:*
Relationship to Patient:*
Today's Date*

MonthDayYear
Cell Phone of Patient/Legal Representative:*

Area CodePhone Number
Home Phone of Patient/Legal Representative:*

Area CodePhone Number
Please let us know which number you would like us to call regarding your medical information. We will leave a message at this number if we do not reach you.*

Home PhoneCell Phone
Vaccine Policy Statement
Principle:
This policy describes the process to meet recommended and required guidelines for pediatric vaccine administration in a longitudinal health maintenance setting.
Scope:
This policy applies to all patients born or entering the practice as a new patient after 09/01/2016.
Clinical Significance:
- Vaccines are safe.
- Vaccines are effective in preventing serious illness and saving lives.
- All children and young adults should receive all recommended vaccines in accordance with the Centers for Disease Control and Prevention (CDC) and American Academy Of Pediatrics (AAP)
- Based on all available literature, evidence, and current scientific studies: vaccines or their preservatives do not cause Autism or other developmental disabilities.
- Vaccinating children and young adults is the single most important health promoting intervention we perform as healthcare providers, and that you can perform as parents/caregivers. The recommended vaccines and vaccine schedule are a result of many years of scientific study and data gathered about millions of children by thousands of our brightest scientist and physicians.
- By asking patients to be fully vaccinated, we are able to protect all of our patients- including those that are too young or medically unable to receive all of their vaccines yet.
Implementation:
- By 2 years of age, all patients in the practice are required to receive the recommended immunizations according to the CDC/AAP Vaccine Schedule.
- The state of Illinois also requires certain vaccines to be given to children entering kindergarten, 6th grade, and 9th grade.
- If you have questions, please discuss these with your healthcare provider. Your provider will make every effort to work with you and answer all of your questions over the course of 3 visits. If you refuse to vaccinate, your provider will follow the following steps below:
Refusal:
- You will be required to sign a refusal to vaccinate acknowledgment and this policy statement at every wellness visit.
- Following the initial refusal to vaccinate visit, 2 more appointments will be scheduled 2 weeks apart to accommodate delayed vaccinations and address any concerns you have about vaccination your child.
- If you should choose to refuse to vaccinate your child after 3 visits, you may be advised to find a healthcare provider who shares your views.
- We do not keep a list of such providers.
Although dismissing you from our practice is regarded as a last resort for our providers:
- Please recognize that by you not vaccinating, your child is at unnecessary risk for life-threatening illness, disability, and even death.
- You also unnecessarily place other children that may come in contact with your unvaccinated child at risk for life threatening illness, disability, and even death.
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 our providers.
American Academy of Pediatrics

http://www.2.aap.org/immunization/families/safety.html
http://healthychildren.org/immunizations
Center for Disease Control and Prevention

http://www.cdc.gov/vaccines
I have read the policy and understand the practices views on caring for my unvaccinated child: Both Patient Name:
Patient Name:*
DOB:*

MonthDayYear
Parent Name:*
Provider:*
Today's Date:

MonthDayYear
Code of Conduct for Patients, Parents and Visitors
In an effort to provide a safe and healthy environment for staff and patients, Alzein Pediatrics expects patients,
parents and accompanying family and friends to refrain from unacceptable behaviors that are disruptive or pose a threat to the rights or safety of other patients and staff. The following behaviors are prohibited and may result in your immediate dismissal from the practice:

• Physical assault or inflicting bodily harm.
• Rude behaviors in person or through written, verbal or electronic communication, including but not limited to the following: Profanity, harassment, offensive or intimidating statements or gestures and threats of violence.
• Racial or cultural slurs or other derogatory remarks associated with race, language, or sexual orientation.
• Requests that would constitute illegal or unethical behavior on the part of Alzein Pediatrics.

PLEASE BE COURTEOUS WITH THE USE OF CELL PHONES/VIDEO AND OTHER ELECTRONIC DEVICES. WE RESPECTFULLY ASK THAT YOU PUT YOUR DEVICES AWAY WHILE INTERACTING WITH THE STAFF, AND PROVIDERS.

WE ARE MAKING EVERY EFFORT TO 􀂹DUCE WAIT TIMES AND MAKE ALL OF OUR PATIENTS' VISITS TO ALZEIN PEDIATRICS AS STRESS FREE AND ENJOYABLE AS POSSIBLE. TO ASSIST IN THAT GOAL, WE HAVE THE FOLLOWING EXPECTATIONS:

Please arrive on time for your appointment. It would be ideal for you to arrive 10-15 minutes early for your appointment. Arrive 10-15 minutes early is especially important when your appointment is our first in the AM.

Arriving more than 15 minutes late may result in having to reschedule. When you arrive late, you are taking up someone else's designated time. This has a domino effect on every subsequent visit and is a contributing factor to long wait times.

❖ Please provide 24 hours notice of cancellation whenever possible. We understand that last minute situations arise. Any notification, even late notice is appreciated.

❖ MISSING an appointment without prior notification will result in a $50 no show fee. That will need to be paid before your childs next appointment.

Please ensure a parent or responsible adult attends all appointments with patients that are 17 years and below. This is necessary to obtain legal consent for all procedures and treatments, including vaccinations.

❖ Payment of co-pays and/ or balances is expected at the time services are rendered, regardless of who brings the child to their appointment. Failure to do so may result in having to reschedule your appointment.

❖ Please do not leave your children unattended in the office. If you need to use the rest room, please inform one of our staff members to help you with your children.

❖ To ensure your children's safety, we ask that you not allow your children to climb on the furniture in the waiting area.
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Caregiver's Name

First NameLast Name
Relationship to Patient:*
Today's Date

MonthDayYear
Date
Signature

Clear
Alzein Pediatrics Financial Policy
We are committed to providing you with the best possible care. If you have medical insurance, we wish to help you receive your maximum allowable benefits. To achieve this, we need your understanding of and assistance with our financial and payment policy.
Insurance: For your convenience, we will submit your claim and assist you in any way we reasonably can to get your claim paid. Insurance plans vary considerably and we cannot predict or guarantee what part of our services will or will not be covered. It is your responsibility to know your individual policy and to verify all benefits and coverage information prior to having services rendered. Your insurance policy is a contract between you and your insurance company.
Insurance Initials:*
Proof of Insurance: Proof of insurance must be shown at check-in at every visit. Without proof of insurance, you will be charged for the visit in full.
Proof Of Insurance Initials:*
Change of Insurance/Change of Address: Please notify the office as soon as possible of all insurance and address changes. If the guarantor does not notify the office within 15 days of any changes the guarantor is responsible for all charges not paid because of change in insurance coverage.
Change of Insurance/Change of Address Initials:*
Newborns: Most commercial insurance companies allow only 30 days to add your newborn to your plan. Please do so as soon as possible. All newborn bills will be held and sent to the insurance company once it can be verified that the newborn has coverage. By 2-months of age, all babies without proof of insurance will be expected to pay in full for their 2-month well visit and all visits since birth.
Newborns Initials:*
Self-pay: We do everything we can to mitigate the expense of anyone who is uninsured. Alzein Pediatrics provides a discount for self-pay patients. Payment is expected in full at the time of service for all charges.
Self-pay Initials:*
Co-Payments: We’re contractually obliged to collect, and you’re responsible to pay, your co-payment at the time of your visit. Please have your co-payment ready at check-in.
Co-Payments Initials:*
Deductibles & Coinsurance: Depending on your insurance policy, a deductible or coinsurance may be required at the time of service. Once the co-insurance amount has been established, the amount due at each visit will be the coinsurance percentage of the charges incurred, plus any deductible not yet met for the year.
Deductibles & Coinsurance Initials:*
Outstanding Balances: Any amount not covered by the insured/patient’s insurance is due within 30 days of the time of service. Balances on account must be paid prior to receiving additional services. Accounts will be turned over to a collection agency if past due 60 days or more. The patient family will be responsible for all collection costs involved with the collection of this account including court cost, reasonable attorney fees and all other expenses incurred with collection if there is a default on any unpaid balance. Should you have extraordinary financial pressure, we will assist you with a payment plan, agreed to in writing with our billing department prior to services being rendered.
Outstanding Balances Initials:*
Credit Card on File: Alzein Pediatrics is committed to making our billing process as simple and easy as possible. We require that all patients provide a credit card on file with our office. If a credit card is not available, we require a $200.00 retainer fee that will be applied towards any patient responsibility as determined by your insurance. Your card number will be saved in a secure PCI compliant site separate from the electronic medical recp. Credit cards on file can be used to pay copays and other charges at the time of the visit. The stored credit card would be used for payments toward patient responsibility, which is determined by your insurance company, unless the amount due is paid in full within 14 days of the statement.
Credit Card on File Initials:*
Coordination of Benefits: Responsible parties must respond to a request for information from the insurance within 10 business days. A failure to respond to a request for COB information from the insurance will result in all charges becoming patient responsibility.
Coordination of Benefits Initials:*
Cancellations: Our office charges a $25.00 no show fee for missed well/routine appointments. If you need to cancel your well/routine appointment, please contact us at least 48 hours in advance. This charge is not covered by your insurance and is the responsibility of the parent/legal guardian.
Cancellations Initials:*
Divorce: In the case of divorce or separation, the parent authorizing treatment for child/children will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent's responsibility to collect from the other parent.
Divorce Initials:*
Transfer of Records: Should you wish to transfer care to another physician, you will need to complete the authorization to release records form, which can be obtained from any of our clinic locations. This form needs to be completed in its entirety for us to process the request. All balances should be paid before records are transferred.
Transfer of Records Initials:*
The doctors at Alzein Pediatrics contract with most insurance plans. However, it is my responsibility to understand the benefits provided in my insurance plan. I am responsible for insurance copayments at the time of my visit, and I am also responsible for any outstanding balance once my insurance claim has been processed. I authorize payment of medical benefits directly from my insurance carrier to the treating physician for services provided.
Name of Parent/Guardian:*
Today's Date:*

MonthDayYear
Date
Relationship:*
Patient Name:
DOB:

MonthDayYear
Should be Empty:

Welcome to Alzein Pediatrics!

PATIENT Information

INSURANCE INFORMATION

In Case of Divorce

Pharmacy Information

Consent by Proxy Pediatrics Care

HIPAA Acknowledgement of Notice of Privacy Practices

Vaccine Policy Statement

Principle:

Scope:

Clinical Significance:

Implementation:

Refusal:

Code of Conduct for Patients, Parents and Visitors

Alzein Pediatrics Financial Policy