New Family/Patient Registration

GROW Pediatrics & Adolescent Medicine, PLLC
1401 Philomena St., Ste 120
Austin, TX 78723
P: 512-467-7334 IF: 512-467-7335
growpediatrics.com
NEW FAMILY DEMOGRAPHICS
Today's Date:*

MonthDayYear
Date
PCP:
How did you hear about us?
PATIENT INFORMATION
Patient 1 Name:*

First NameMiddle InitialLast Name
Nickname:
Date of Birth:*

MonthDayYear
Date
Gender:*
Patient 2 Name:

First NameMiddle InitialLast Name
Nickname:
Date of Birth:

MonthDayYear
Date
Gender:
Patient 3 Name:

First NameMiddle InitialLast Name
Nickname:
Date of Birth:

MonthDayYear
Date
Gender:
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GUARANTOR INFORMATION (PARENT HOLDING INSURANCE)
Relationship to patient:*
Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Date
Cell Phone*
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Address (if different):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:*
example@example.com
Employer:
Insurer:
Policy/Member ID:
Group Number:
ADDITIONAL PARENT INFORMATION (NOT INSURANCE SUBSCRIBER)
Parent: Name

First NameMiddle InitialLast Name
Date of Birth:

MonthDayYear
Date
Relationship to patient:
Address (if different):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Employer
Email:
example@example.com

FAMILY INFORMATION
Are the patient's parents divorced/separated?*
If so, is custody shared?
YesNo
GROW has a policy relating to family dynamics that clearly outlines boundaries/expectations surrounding communication, access to records and appointments, and parent responsibility. If this applies to your family, we'll be happy to provide you with a copy of this policy.
CONTACT OPTIONS
Guarantor's Phone NumberOther Parent's Phone NumberBoth
Authorization for Voicemail Usage for PHI: I hereby give permission to leave a message on the voicemail concerning my child's personal health information. Please initial to ACCEPT:*
Guarantor's EmailOther Parent's EmailBoth
PHARMACY INFORMATION
Preferred Pharmacy:*
Address/Cross Streets:*
Phone:
Format: (000) 000-0000.

Rows	Date of Diagnosis (mth/yr)	Condition
1
2
3

Rows	Date (mth/yr)	Surgical Procedure
1
2
3

Rows	Date (mth/yr)	Reason for Hospitalization
1
2
3

Rows	Allergen	Reaction/Symptoms
1
2
3

CONSENT TO TREATMENT OF A MINOR
GENERAL CONSENT

APPLICABLE PATIENT(S)*

Rows	Last Name	First Name	Date of Birth
1
2
3
4

Authorize
TO PERMIT SPECIFIED INDIVIDUALS TO ACCOMPANY CHILD(REN)
Authorize (list individuals below)Do Not Authorize

Rows	First and Last Name	Phone Number	Relationship to Patient
1
2
3
4

CONSENT TO TREAT UNACCOMPANIED MINOR (16 AND OLDER)
AuthorizeDo NOT Authorize
NOTE: Per GROW Pediatrics policy, certain immunizations require the patient to stay in our waiting room 15 minutes POST administration. For their safety, please allow for this time in your child(ren)'s schedule.
SIGNATURE OF PATIENT/PARENT/LEGAL REPRESENTATIVE
Signature of Patient/Parent/Legal Representative*
Date*

MonthDayYear
Date
Printed Name of Patient/Parent/Legal Representative*
Relationship to Patient*

PATIENT FINANCIAL POLICY
In compliance with the Federal Consumer Protection Act, GROW PEDIATRICS AND ADOLESCENT MEDICINE, PLLC wishes to notify you of our policies regarding the financial responsibilities associated with services rendered to your child. Acknowledgement of this policy is required to receive treatment.
Insurance
It is your responsibility to familiarize yourself with the details of your insurance policy. It is your responsibility to confirm with your insurance carrier that GROW is considered to be "in-network" with your specific plan. Please refer to the Member Services phone number on your ID card. As a courtesy, we will bill your insurance company, provided we have the correct billing information at the time of service. If a claim is denied because you have not provided correct and active insurance details, the charges will transfer to your responsibility. As a courtesy, we will provide to you any information we have acquired requiring your specific benefits, and your estimated cost. Co-Pays are required to be paid at the time of service. You are financially responsible for charges deemed by the insurance company to be billable to the patient. You must be familiar with your particular coverage and any requirements for pre-authorization, deductibles, and limitations on well child visits, lab services, immunizations, and other procedures.
Self-Pay Account
If proof of valid insurance is not provided, your account will be considered self-pay and payment in full of all charges will be required at the time of service. In accordance with the No Surprises Act of 2022, at your request, you will be provided with a Good Faith Estimate from GROW prior to your appointment; provided that the appointment is scheduled two or more business days prior to the date of service. If you subsequently provide verifiable insurance information, and the time frame for billing the insurance has not expired (generally 45-90 days), we will bill the charges to your insurance company for you. If we then receive insurance payment, we will promptly issue a refund to you of any credit on your account.
Billing and Collections
The billing statement you receive will show patient balances due, in addition to insurance company payments, adjustments, and pending amounts. Patient balances are due from you upon receipt of the statement. Balances can be paid online on the GROW Patient Portal (link can be found on our website) or by calling our office directly and choosing the option for the Front Desk. Accounts left outstanding with no good faith effort to resolve the balance will be sent to National Healthcare Collections, LLC. Once a patient account is in collections, GROW cannot take payment toward the balance in question. To arrange payment with NHC, please contact them at (877) 313-4138.

Appointments
Please remember that your appointment time is reserved just for you. Our schedules are full each day and we must leave enough room in our schedule to bring in sick children on the same day. If your appointment is missed or cancelled with less than 24 hours' notice, consider that another child could have been seen at that time. We reserve the right to charge a $50 cancellation or 'no show' fee, beginning with your family's second occurrence. In order to see each patient on time, it is our policy that your appointment will likely be rescheduled if you arrive more than 15 minutes late.
After Hours Phone Calls
Our office hours are Monday-Friday 8:00am-5:00pm. To utilize our After Hours nurse triage, please call our main number and follow the appropriate prompts. There is a $25 charge that will be billed to you for this service. Our triage service does have access to an on-call physician for urgent matters regarding such attention.
Saturday Visits
We charge an after-hours fee for physician visits held after regular business hours, such as Saturday clinic visits. This fee is $40 and is paid out of pocket, as it's generally not covered by insurance carriers. This fee is collected at the time of service.
ASSIGNMENT OF BENEFITS/MEDICAL RELEASE AUTHORIZATION
I authorize the release of any medical or other information necessary to process my child's insurance claim. I authorize payment of medical benefits to GROW PEDIATRICS AND ADOLESCENT MEDICINE, PLLC for services rendered and agree to abide to the above noted financial policy. My signature below also acknowledges my understanding and agreement to comply with this Financial Policy, as stated.
Parent/Guardian Signature*
Date*

MonthDayYear
Date
Patient Name*
Date of Birth*

MonthDayYear
Date
Should be Empty:

Rows	Reason/Condition	Specialist Name	Approximate date(s)
1
2
3
4

Rows	Mother	Father	Sibling	Grandmother	Grandfather	Aunt/Uncle	Cousin
Arrhythmia
Heart attack
Heart murmur
High cholesterol
High blood pressure
Stroke or TIA
Seizures or epilepsy
Migraines
ADHD/ADD/Learning disorder
Dementia or Alzheimer's
Depression/Anxiety
Bipolar Disorder
Eczema
Acne
Asthma
(elabor ate type/Individual below)

Rows	Mother	Father	Sibling	Grandmother	Grandfather	Aunt/Uncle	Cousin
Cystic fibrosis
Huntington's Disease
Fragile X
Muscular dystrophy
Diabetes mellitus
Thyroid disease
Growth disorder
GERD
IBS
Celiac disease
Anemia
Bleeding/clotting disorder
Auto-immune disease
Hearing or vision problems
Developmental delay
Autism Spectrum Disorder

NEW FAMILY DEMOGRAPHICS

PATIENT INFORMATION

GUARANTOR INFORMATION (PARENT HOLDING INSURANCE)

ADDITIONAL PARENT INFORMATION (NOT INSURANCE SUBSCRIBER)

FAMILY INFORMATION

CONTACT OPTIONS

PHARMACY INFORMATION

OFFICE VACCINE POLICY

PART 1: PATIENT

MEDICAL HISTORY

Has your child undergone any surgery?

Has your child ever been hospitalized?

Does your child see any medical specialists?

Does your child have any allergies or adverse reactions to food or drugs, etc?

Does your child currently take any medications, vitamins or supplements?

DEVELOPMENTAL

Birth Information

PART 2: FAMILY

HOUSEHOLD

FAMILY HISTORY

CONSENT TO TREATMENT OF A MINOR

GENERAL CONSENT

TO PERMIT SPECIFIED INDIVIDUALS TO ACCOMPANY CHILD(REN)

CONSENT TO TREAT UNACCOMPANIED MINOR (16 AND OLDER)

SIGNATURE OF PATIENT/PARENT/LEGAL REPRESENTATIVE

PATIENT FINANCIAL POLICY

Insurance

Self-Pay Account

Billing and Collections

Appointments

After Hours Phone Calls

Saturday Visits

ASSIGNMENT OF BENEFITS/MEDICAL RELEASE AUTHORIZATION

Rows	Name	Dosage	Frequency
1
2
3
4