New Patient Form English

New Patient Form English
Patient Name*

First NameLast Name
DOB*

MonthDayYear
Date
Sex*
Race*
Ethnicity*
Language*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Prior Records
Previous records may be obtained from:
Name of previous doctor or Medical Practice (if applicable).
Phone Number
Phone of previous doctor or Medical Practice (if applicable).
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pharmacy Information
Pharmacy Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parents Information
Mother's Name*

First NameLast Name
DOB*

MonthDayYear
Date
Email*
example@example.com
Phone (Home)
Please enter a valid phone number
Phone (Cellphone)
Please enter a valid phone number

Parents Information
Father's Name *

First NameLast Name
DOB*

MonthDayYear
Date
Phone (Cellphone)
Please enter a valid phone number
Email
example@example.com
Address (if not the same as the patient’s):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian ID*

Cancelof

Insurance Information
Self-Pay? (If not, please complete the insurance information below.)*

YesNo
Insurance Company Name
Policy Number
Policy Holder Name
Group Number
Insurance Phone Number
Please enter a valid phone number
Insurance ID (Front & Back)

Cancelof

Emergency Contact
Contact Name*

First NameLast Name
Relationship to Patient*
Emergency Contact Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Financial Responsibility Acknowledgment
My Way Pediatrics

By signing below, I acknowledge that I am financially responsible for all medical services provided by My Way Pediatrics, including any amounts not covered by insurance.

Locations:

Royal Palm Beach: 1410 Royal Palm Beach Blvd, Royal Palm Beach, FL 33411
West Palm Beach: 2051 45th St, Bldg A, Suite 100, West Palm Beach, FL 33407
Weston: 2771 Executive Park Dr, Suite 1, Weston, FL 33331

Insurance Responsibility:
Insurance is considered a method of reimbursing the patient for fees paid to the provider and is not a substitute for payment. It is the patient’s responsibility to ensure that all insurance information provided to our office is accurate and up to date. Patients are responsible for paying all deductibles, co-payments, co-insurance, and any balances not covered or paid by their insurance provider. Please understand that some insurance companies pay only a portion of the charges or have limitations on coverage. Therefore, any amount not reimbursed by your insurance is your personal responsibility.

Payment Expectations:
To help manage the cost of healthcare and maintain efficient services, we require that all payments, including co-pays, co-insurance,deductible and any outstanding balances, be paid at the time of service unless prior arrangements have been made with our billing department. We accept various payment methods for your convenience. If payment is not made at the time of service, we reserve the right to reschedule future appointments until the balance is settled.

Authorization for Release of Information:
By signing this agreement, you authorize My Way Pediatrics to release any necessary medical information and documentation to your insurance provider(s) to facilitate the processing of claims. This authorization allows our office to communicate with your insurance company to verify benefits, obtain prior authorizations, and handle claim denials or disputes on your behalf.

Coverage Responsibility:
You are responsible for understanding the specifics of your insurance plan, including coverage limitations, network restrictions, referrals, and pre-authorization requirements. If your insurance plan (including Medicare, Medicaid, HMO, PPO, or any other) does not cover certain services rendered, or denies payment for any reason, you agree to pay for those services personally. It is also your responsibility to inform our office promptly of any changes to your insurance coverage, such as policy renewals, changes in providers, or changes in insurance companies.

Ongoing Consent:
This Financial Responsibility Agreement will remain in effect for all future visits and services provided by My Way Pediatrics until you provide written notice revoking or amending it. Any such revocation or changes must be submitted in writing to our office.

No Insurance:
If you do not have insurance coverage, you are fully responsible for all charges related to the medical services you receive. Payment is expected in full at the time services are provided unless prior arrangements are made with the billing office. We are happy to discuss available payment plans or financial assistance options if needed.

Returned Checks:
Any check returned by the bank due to insufficient funds or any other reason will incur a fee of $25 in addition to any charges imposed by your bank. After a returned check, payment must be made by cash, money order, or credit card.

Missed Appointments and Cancellations:
To provide timely care to all patients, we require at least 24 hours’ notice for appointment cancellations or rescheduling. Failure to provide adequate notice will result in a $20 missed appointment fee. Repeated no-shows or late cancellations may result in the inability to schedule future appointments.

Acknowledgment and Agreement:
I have read, understand, and agree to the terms outlined in this Financial Responsibility Acknowledgment. I accept full financial responsibility for all charges incurred as a patient or guardian of a patient at My Way Pediatrics. I understand that I am responsible for payments not covered or reimbursed by my insurance. I hereby authorize My Way Pediatrics to bill my insurance and release necessary information for claims processing.
Signature*

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CONSENT, PERMISSION, AND RELEASE
For Use of Photo, Video, and/or Audio

I hereby give full consent and permission to MY WAY PEDIATRICS ASSOCIATES, LLC to record my (or my child’s) image, voice, and/or physical likeness by photo, video, audio, or other media formats.

In accordance with Florida Statutes, including any applicable provisions under Section 540.08, I voluntarily authorize the use and publication of my (or my child’s) name, image, and/or likeness by MY WAY PEDIATRICS ASSOCIATES, LLC, its staff, employees, agents, or any associated entity. This authorization includes, but is not limited to, use for educational, promotional, advertising, marketing, and trade purposes, in any format or media, including film, photo, television, radio, digital platforms, internet, or public exhibition.

This consent remains in effect from the date signed and will continue unless revoked by me in writing.
I agree

YesNo
Signature*

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Consent by Proxy for Pediatric Care
Purpose: This form authorizes an adult other than a parent or legal guardian to make decisions and consent to routine medical care and services for the listed child(ren).

I/We hereby appoint the following individual(s) as proxy decision-maker(s) authorized to consent to medical care for my/our child(ren). I/We affirm that I/we have the legal authority to delegate this responsibility, and that the individual(s) designated are adults and legally and medically competent to do so. I/We understand that protected health information about the patient may be shared with the proxy as necessary for appropriate medical decision-making.
Patient*

First NameLast Name
DOB*
Person Authorized by Parents

First NameLast Name
DOB

MonthDayYear
Date
Relatioship to the patient
Signature*

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Medical Consent and HIPAA Authorization for Use of Scribe AI
My Way Pediatrics
By signing below, I consent to the use of Scribe AI for documentation purposes during my child’s medical visits. I authorize My Way Pediatrics to use and disclose my child’s health information in compliance with HIPAA regulations.

Locations:

Royal Palm Beach: 1410 Royal Palm Beach Blvd, Royal Palm Beach, FL 33411
West Palm Beach: 2051 45th St, Bldg A, Suite 100, West Palm Beach, FL 33407
Weston: 2771 Executive Park Dr, Suite 1, Weston, FL 33331 of This Form
The purpose of this form is to provide clear information and obtain your consent for the use of artificial intelligence (AI) technology—specifically Scribe AI—during your child’s medical visits. This ensures transparency and supports our goal of enhancing care through efficient documentation.

What is Scribe AI?
Scribe AI is a secure, HIPAA-compliant software tool designed to assist healthcare providers by capturing and transcribing conversations during medical appointments. By using this technology, providers can devote more attention to your child and less time on note-taking during the visit.

How Your Child’s Information is Used
Scribe AI may record and process audio and/or transcriptions of your child’s visit strictly for the purpose of medical documentation.
All data is encrypted, securely stored, and handled in accordance with HIPAA privacy and security regulations.
Your child’s information will not be sold, shared for marketing purposes, or used outside the scope of clinical documentation.

Your Rights and Protections
You may decline or withdraw your consent at any time without affecting your child’s medical care or treatment.
You may request details about how your child’s data is used, stored, and protected.
A copy of the provider’s visit note will be available upon request.

Consent
I have read and understood the information provided above. I hereby give consent for My Way Pediatrics to use Scribe AI during my child’s visit. I authorize the collection, use, and secure storage of my child’s health information for the sole purpose of medical documentation as outlined in this form.
Signature*

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This notice describes how medical information about you may be used and disclosed and how you can access this information.
PLEASE REVIEW IT CAREFULLY.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION:
The following outlines how we may use and share your health information. Unless permitted by law or described below, we will not use or disclose your health information without your written authorization. You may revoke your authorization at any time in writing.

Treatment:
We may use or disclose your health information to provide, coordinate, or manage your medical care. This may include sharing information with doctors, nurses, technicians, or other healthcare professionals involved in your care, including individuals or facilities outside our practice.

Payment:
We may use and disclose your information to obtain payment for the treatment and services you receive. For example, we may share necessary information with your insurance company to process claims.

Healthcare Operations:
We may use and disclose your information for administrative, financial, legal, and quality improvement activities. This ensures you receive quality care and allows us to operate efficiently. For example, we may share information with your insurance company to support their healthcare operations.

Appointment Reminders, Treatment Alternatives, and Health-Related Benefits:
We may use your health information to remind you of appointments or inform you of treatment options or services that may benefit your health.

Individuals Involved in Your Care or Payment:
When appropriate, we may share your information with family members, friends, or others involved in your care or payment for services. We may also notify them about your condition, location, or in emergency situations, as allowed by law.

Research:
Under certain conditions, we may use or disclose your information for research purposes. All research projects are subject to a special approval process. Researchers may review your information to help identify potential study participants.

Fundraising Activities:
We may use your contact information to communicate with you for fundraising purposes. You have the right to opt out of receiving these communications. If you wish to do so, please notify our Privacy Officer in writing.

SPECIAL SITUATIONS
As Required by Law:
We will disclose your information when required by federal, state, or local law.

To Prevent a Serious Threat to Health or Safety:
We may disclose your health information to prevent a serious threat to your health and safety or that of the public or another person.

Business Associates:
We may disclose your information to third-party service providers ("business associates") who perform services on our behalf, such as billing. All business associates are required by law to protect your privacy.

Data Breach Notification:
We may use your contact information to notify you in case of a data breach involving your health information, as required by law.

Organ and Tissue Donation:
If you are an organ donor, we may share your information with organizations involved in organ donation and transplantation.

Military and Veterans:
If you are a member of the military, we may release your information as required by military authorities.

Workers’ Compensation:
We may release your health information as authorized by laws relating to workers’ compensation or similar programs.

Public Health Activities:
We may disclose your information for public health purposes such as:

Preventing or controlling disease, injury, or disability
Reporting births and deaths
Reporting child abuse or neglect
Reporting adverse reactions to medications or defective products
Notifying people exposed to communicable diseases
Reporting to authorities when we believe an individual may be a victim of abuse or domestic violence, as permitted or required by law

YOUR RIGHTS REGARDING HEALTH INFORMATION
Access to Records:
You have the right to inspect and receive a copy of your medical and billing records. If these are maintained electronically, you may request a digital copy in your preferred format. To request access, you must submit a written request.

Right to Amend:
If you believe your health information is incorrect or incomplete, you may request an amendment in writing. We may deny your request in certain cases, but we’ll notify you of the reason.

Right to an Accounting of Disclosures:
You may request a list of disclosures made of your health information (other than for treatment, payment, or healthcare operations). This request must be made in writing.

Right to Request Restrictions:
You may request limitations on how we use or disclose your information for treatment, payment, or healthcare operations. You may also request restrictions on sharing your information with certain people, such as family members. We are not required to agree to your request unless it involves restricting disclosures to a health plan for services you paid for out of pocket in full.

Right to Request Confidential Communications:
You can request that we contact you in a specific way (e.g., only by mail or at work). This request must be in writing and must specify how or where you want to be contacted.

Right to a Paper Copy of This Notice:
You may request a paper copy of this notice at any time, even if you have received it electronically.

CHANGES TO THIS NOTICE:
We reserve the right to change this notice and apply the new practices to health information we already have and any we may receive in the future. The updated notice will be available in our office and on request.

COMPLAINTS:
If you believe your privacy rights have been violated, you may file a complaint with our office or with the U.S. Department of Health and Human Services.
Complaints must be submitted in writing.
You will not be penalized for filing a complaint.

CONTACT INFORMATION
My Way Pediatrics

Royal Palm Beach Office
1410 Royal Palm Beach Blvd
Royal Palm Beach, FL 33411
Phone: (561) 423-9944
Fax: (561) 328-6031
Attention: Compliance Contact

West Palm Beach Office
2051 45th St, Bldg A, Suite 100
West Palm Beach, FL 33407
Phone: (561) 844-2233

Weston Office
2771 Executive Park Dr, Suite 1
Weston, FL 33331
Phone: (754) 348-3899
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New Patient Form English

Prior Records

Pharmacy Information

Parents Information

Parents Information

Insurance Information

Emergency Contact

Health History