Congratulations on your newborn!
We like to see all newborns within 5 days of birth, so if you have not already done so, please call us as soon as possible to schedule an appointment after submitting this form.
Patient is above 18; parent information not required.
Awesome! Please provide an email address above (Parent 1 Email) for {q29_fullname27} to fill out and sign separate consent forms. These forms must be signed prior to any services.
Awesome! Please provide an email address above (Parent 2 Email) for {q30_fullname28} to fill out and sign separate consent forms. These forms must be signed prior to any services.
Patient Name: {patientName}DOB: {patientDate}Consent to Treatment. I consent to and authorize the providers and staff at Grow Pediatrics to perform appropriate healthcare examinations, treatment, diagnostic testing, or medication administration as deemed medically necessary by their professional judgment. I am aware that all medical treatments and procedures carry risks, and I understand that no one can guarantee their effectiveness. Grow Pediatrics is a teaching clinic, and I may receive care from other providers or staff who are in training and supervised by licensed healthcare providers. I may decline to have these individuals involved in my care, and this will not affect my care or treatment.Assignment of Benefits/Payment for Services. I authorize payment of any and all benefits to Grow Pediatrics. I understand that I am responsible for any charges for my care that are not covered by my insurance, health plan, or government programs. I realize I must cooperate with Grow Pediatrics to get payment for my care. If I am eligible for payment from more than one type of coverage, Grow Pediatrics will return any extra payments to the payor. If I have an unpaid bill at Grow Pediatrics, any refunds due to me will be applied to my outstanding balance. If any money remains after my bill is paid, I will receive a refund from Grow Pediatrics.Release of Information. I consent to and authorize Grow Pediatrics to use and disclose my protected health information for treatment, payment, and health care operations, including care coordination, quality assessment, and improvement activities. Releases for these purposes may be made to consultants who are being advised or consulted in connection with my treatment, insurance companies, health plans, e-prescribing services, record locator services, payer network organizations, including clinically integrated networks and/or accountable care organizations in which my provider participates, and other healthcare providers involved in my care and treatment, including any business associates of these organizations. Grow Pediatrics may take photos and/or videos during your medical care, and these photos and or videos may be used for care, quality assessment and improvement, and medical education. Additionally, I consent to and authorize my insurance company to share any of my protected health information for the purposes stated above to Grow Pediatrics and/or a clinically integrated network or accountable care organization in which Grow Pediatrics participates.Patient Rights and Privacy Practices. You and your family’s rights and our privacy practices are posted in the main areas within Grow Pediatrics. Your signature acknowledges receipt of our Notice of Privacy Practices. If you have any questions concerning your rights and/or our privacy practices, please contact your care provider or Grow Pediatrics’ Privacy Officer.Mobile Phone Consent. Yes, Grow Pediatrics may call my provided mobile phone number about the care, treatment, services, and accounts using pre-recorded messages, automatic telephone dialing systems, and/or text messages. Standard text message and minute usage rates may apply. I am aware that information in a voice or text message may not be secure and that providing this consent is not a condition of receiving treatment.Name: {yourName}
Patient Name: {patientName}DOB: {patientDate}Health Information Exchange. I consent to Grow Pediatrics and my providers electronically obtaining and sharing my child’s health care information for coordinating my child’s care and treatment. This consent permits Grow Pediatrics and its providers to: 1) electronically request and obtain my/my child’s health records from other health care providers that have provided care and treatment to me/my child; and 2) make my/my child’s Grow Pediatrics medical records available electronically to other health care providers who provide care to me. These records may include testing, diagnosis, treatment, demographic and registration records created in the course of providing services to me/my child for all medical and health conditions, including but not limited to, family medical history, patient and/or family histories of behavioral and mental illness, developmental disabilities, recreational or illicit drug use/abuse/dependency, sexually transmitted illnesses, or other items of a social history nature. If you have specific requests for how your/your child’s health information should be used or disclosed, those requests may not be shared through the electronic health information exchange. You should discuss those specific requests with your other healthcare providers. Provider Record Locator. A health record locator service helps your health care provider determine where you have received care. I consent to Grow Pediatrics and my providers accessing my information in a record locator. I also consent to Grow Pediatrics and my providers making my information available in a record locator for search by other healthcare providers who may provide me/ my child’s care and treatment. If you do not want Grow Pediatrics and your providers to utilize a record locator for accessing and sharing your health information, you must check this box. You may cancel or revoke this consent by writing to: Grow Pediatrics at 5975 Carmen Ave, Inver Grove Heights, MN 55076. If this consent is canceled or revoked, it will not affect releases that have already occurred before receiving your written cancellation. My signature here indicates that I have read and understand the information on this form. This consent is valid until revoked.Name: {yourName}
Patient Name: {patientName}DOB: {patientDate}Agreement to Pay All Charges for Services Rendered. In consideration of providing services, I agree to pay all charges for services provided to me, to my minor children, or to any minor child for whom I have authority to make medical decisions, that are not covered by any benefit plan. I expressly guarantee payment of all charges for medical services rendered, or to be rendered, by Grow Pediatrics to me, my minor children, or any child for whom I have authority to make medical decisions.Financial Policy Terms. I understand and agree to Grow Pediatrics’ financial policy terms. Current policy terms are listed below. However, Grow Pediatrics reserves the right to amend the terms of this policy at any time. I understand that any policy changes will be made only on Grow Pediatrics’ website, and I waive any right to receive notice of those changes by any other method. I understand this authorization will remain in effect until I revoke it in writing.
Insurance Reminder. Your insurance coverage contract is an agreement between you and your insurance company. The amount your insurance company pays is determined under the terms of your contract. You are responsible for any amount not covered under your contract and any pending insurance claims. It is your responsibility to know your coverage plan, including which services are covered and which are not.Copays. Copays are due at the time of service. This is a requirement of your insurance plan. Copays not paid at the time of the visit are subject to a $25 surcharge. Billing Statements. Please retain a copy of all billing statements; Grow Pediatrics does not guarantee that any statements can be reproduced.Accepted Payment Forms. We accept cash, check, money order, and all major credit & debit cards. When you provide a check as payment, you authorize us to either use information from your check to make a one-time electronic funds transfer from your account or to process the payment as a check.Responsible Party. We hold both parents separately and jointly liable for all outstanding charges if the patient is under 18.Delinquent Accounts. Failure to pay your bill may result in your account being sent to an outside collections agency and/or being reported to credit reporting agencies. Any delinquent account, including any associated account(s), may be required to pay for any future visit prior to service or may be unable to schedule future appointments until the total balance is paid.Name: {yourName}
By filling out this form, I, being the patient, parent, or legal guardian of the patient, do hereby request that the listed provider or clinic release medical records as specified by the form below.
Patient Name: {patientName} DOB: {patientDate}Address: {q9_address7}I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. I understand that no other uses will be made of this information, except for those previously communicated to me or as otherwise authorized by law, and that access to such information will be limited to persons whose work assignments reasonably require access to accomplish the purposes stated above. I understand that I may revoke this consent at any time in written form. In any event, this consent expires within one calendar year of this date or remains in effect for the period reasonably needed to complete the request for information, whichever occurs first. I release the above-named healthcare provider from all legal responsibility and/or liability that may arise from the release of the records I have specified. I direct that only information prior to the date of my signature be honored, and that a photocopy or fax copy of this authorization be granted the same authority as the original. I understand that I may refuse to sign this authorization, and that my refusal to sign will not affect my ability to obtain treatment or payment, or my eligibility for benefits, except as permitted by law. I understand that there may be a charge incurred for copies of medical records pursuant to MN Statute 144.335 and rule 164.524.Name: {yourName}