Adult Patient Registration

 1. Give the doctor and staff permission to examine and treat me.

2. Authorize release of information to my insurance carrier for the purpose of processing claims. I hereby assign medical insurance benefits, to include major medical to the doctors at Lone Star Kids Care. Pay for services when rendered unless other arrangements are made prior to the visit.

3. Should my account become delinquent, I agree to pay the necessary outstanding balance/fees.

4. Use the after-hours call service only for urgent purposes.

5. Be financially responsible for all charges deemed to be "non-covered benefits" by my insurance company even if the insurance's Explanation of Benefits state the procedure is a "non-covered benefit" and "patient is not responsible."

6. Keep appointments in a timely manner. If not, I realize there is a $50 fee if I no call/no show to my Well/ADHD/Asthma/Depression/Anxiety. appointment within 24 hours of the scheduled time Same day sick visits require a 2 hour notice. If I call after the 2 hour mark, I will be charged a no show fee of $50 as well.

Permission is granted to the physicians and employees of Lone Star Kids Care to do such procedures as may be necessary to diagnose, treat, and care for the needs of myself (if 18 years old or older), or of my dependent minor child including but not limited to routine office and laboratory procedures such as strep tests and throat cultures, urine studies, complete blood counts (CBC), hematocrits, bladder catheterization, removal of cerumen (ear wax), removal of foreign bodies, drainage of abscess, fracture care, medication injections, and treatment of skin lesions, warts, burns, and lacerations.

This assignment will remain in effect until revoked by me in writing.

Lone Star Kids Care may need to contact you about test results, appointments, referrals, or billing/insurance information. To protect your privacy and follow federal guidelines, unless we have written permission to do so. We will NOT leave messages or discuss medical information with anyone except the patient or legal guardian without permission. We will NOT leave messages containing medical information on voicemail or answering machines without permission. I give my permission for my provider(s) of Lone Star Kids Care to leave phone messages regarding my medical care/account information. I fully understand that this consent will remain valid until revoked in writing by me.

1. Copayments and Deductibles: All copayments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co- payment and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment or required portion at each visit.

2. Insurance: We participate in most insurance plans. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we are contracted with, but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits and coverage is your responsibility, as we only get a general quote of benefits. We do not file secondary insurance. Our insurance plans are through Accountable Care Organizations. Please contact your insurance provider with any questions you may have regarding your coverage.

3. Non-Covered Services: Please be aware that some services you receive may not be covered or not considered necessary or reasonable by your insurance provider. It is your responsibility to understand your benefit plan. Not all insurance plans cover Well Child Visits, Sports Physicals, Vision and Hearing screenings, Depression screening, Lead screening, Cholesterol or LIPID Panels, and Vaccines. If not covered, you will be required to pay for these services in full.

4. Proof of Insurance: Upon arrival, before seeing the provider, we must obtain a copy of your current insurance card to verify that we have the most up-to-date insurance card on file. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of the claim.

5. Claims Submission: We will submit your claims and assist you in any way we can to help get your claims paid. Your insurance provider may require you to provide them with certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether your insurance company pays or not. Your insurance benefit is a contract between you and your insurance provider. We are not a party to that contract.

6. Well Child Visits: Every well child visit is unique. Sometimes, a well child visit can involve medical care beyond the regular check-up. If additional medical needs or concerns are encountered or managed during a well care visit, your health insurance plan may require further charges and copayments to be applied.

7. Medical Records: When transferring to a new pediatrician, there is no charge to send your child's medical records directly to their new physician, however, we will need a medical records release filled out and signed by a parent to do so. If the parent requests a copy of their child's medical records to be released to them directly, there is a charge of $25.

8. Bounced Checks: Any bounced checks will have a $25 fee.

9. Payment Plans: Your child's welfare is our number one priority. We will try to work with parents when financial hardships arise. Please let our office know if your financial situation changes and we can set up payment arrangements.

1. Minors at Appointments: All patients under the age of 18 must be accompanied by an adult for their appointments. If the accompanying adult is NOT the parent/guardian, they must be over the age of 18 and have a consent to treat form on file.

2. No Show Policy: Appointments are scheduled at the request of each individual patient. All well visits, adhd, asthma, depression, anxiety visits require a 24 hour cancellation notice. All same day sick visits require a 2 hour notice of cancellation. You will be charged a $50 fee to the patient's account if failure to do so and will be billed directly to you as the parent's responsibility. If you have three of these in one year, you may be dismissed from the practice. Please help us serve you better by keeping your regularly scheduled appointments.

3. Late Policy: Appointments are scheduled at the request of each individual patient's parent. If you are more than 15 minutes late to your child's scheduled appointment, your appointment may be cancelled, you may be asked to come back at an open time, or be worked back into the schedule with a wait. The decision is up to the individual provider.

4. Prescription Refills: Chronic or routine meds may be refilled by calling your pharmacy. Please have the pharmacist send us a prescription refill request. However, antibiotics or medications for new problems will not be called in unless the patient is seen in the office. For ADHD specialized scripts, please send in a refill request through the patient portal. We require a 72 hour notice so please plan accordingly.

5. Appointments: We see patients by appointment only. We do not see walk-in patients. We will make every effort to see sick patients on a same-day basis. Well child visits should be scheduled in advance as much as possible.

6. School Notes: You may request a school note for when your child is seen in the office. Notes will not be given over the phone if the child was not seen in the office.

7. Nurse Calls: A nurse is available to answer your questions during our normal business hours. Because these calls are returned in order of medical urgency, you will be asked to leave a message. Please understand, we have many messages left on a daily basis, so you may receive a call back towards the end of the day. If you feel your child will need to be seen in the office, please schedule an appointment.

8. Splitting Up Vaccines: All doctors at LSKC follow the immunization schedule recommended by the American Academy of Pediatrics (AAP If you choose to split up your child's vaccines outside of the AAP's recommended immunization schedule, your child will be scheduled with a nurse for these visits. A nurse visit will be billed to your insurance company. Some insurance companies may not consider this visit as 'preventative' since it is not billed with a well exam. If your insurance company doesn't cover the nurse visit in full, you understand that you will be responsible for the charges.

9. Records: To protect your child's records, we ask you to provide our office with a driver's license or other picture identification. Yearly, or as changes occur, we will ask you to update Patient Information Forms, Insurance card and ID. We will check these documents prior to releasing your child's records.

The Department of Health and Human Services has established a "Privacy Rule" to help ensure that personal health care information is protected for privacy. The Privacy Rule was also created to provide a standard for health care providers to obtain their patient's consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health concerns.

When it is appropriate and necessary, we provide the minimum necessary information to only those we feel need your health care information and information about treatment, payment, or health care operations, in order to provide health care that is in your best interest.

You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or previously signed consent.

If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer. You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice. I acknowledge that this consent will remain in effect for 24 months from the date of this consent unless I revoke it earlier as described above.

I hereby give consent to the office of Lone Star Kids Care to use and disclose my (or my child's) protected health information for the purposes of treatment, payment, or healthcare operations.