Please sign in at the front desk with your current insurance information and have it available at each of your child's visit. As soon as we have your baby scheduled to come in, you will need to contact your insurance to add him/her to your current plan. Our office will give you 45 DAYS to get your baby added and verified under your plan. IF WE CANNOT VERIFY COVERAGE at that point, we WILL NOT schedule your baby for their 2 month Well Child Exam, or any appointments moving forward until we can verify the baby has been added and we can verify their benefits,
NO EXCEPTIONS!

You can choose to pay each visit in cash until the baby is added. Once added, we will refile any visits and once paid, we are happy to credit or refund the account.

Some insurance plans will not pay for services unless your child's physician is designated as his/her PCP (Primary Care Physician). Make sure this is taken care of during the enrollment process, OTHERWISE YOU COULD BE RESPONSIBLE FOR ANY UNPAID VISITS DUE TO LACK OF INFORMATION TO YOUR INSURANCE COMPANY.

I have read and understand the office financial policy for newborns and agree to comply and accept responsibility for any payment that becomes due as outlined.

parent / legal guardian of:

Do hereby give my authorization and consent for my child (named above) to be seen by Providers at Mansfield Pediatrics, PLLC and consent to the medical/surgical care and treatment of my child(ren). I hereby authorize and grant that the below named person(s) has/have permission from the natural parents to sign for any medical/surgical procedures or treatments deemed necessary for the well-being of my child(ren). This is also permission to bring my child(ren) for well checks and all necessary immunizations that are routinely given at the well visit.

I am, by this document, representing that I have the authority to consent for all medical/surgical care and treatment of said child(ren):

Please read the following carefully and direct any questions you may have to the front office staff.

Payment for services is due on the day of your child's visit. Our cash prices are based on an insurance reimbursement average.

Please sign in at the front desk and present your child's current insurance card at every visit. This is your verification of the correct insurance and consent to bill for services on your child's behalf. IF THE INSURANCE PLAN THAT YOU DESIGNATE IS INCORRECT OR NOT IN FORCE, THEN YOU ARE RESPONSIBLE FOR PAYMENT OF THE VISIT AND YOU WILL BE BILLED FOR THE VISIT UNTIL YOU PROVIDE THE CORRECT INSURANCE PLAN INFORMATION FOR THE OFFICE TO FILE FOR PAYMENT OF SERVICES. THIS INFORMATION MUST BE RECEIVED WITHIN 30 DAYS OF THE DATE OF SERVICE DUE TO INSURANCE FILING DEADLINES... NO EXCEPTIONS!

Some insurance plans will not pay for services unless your child's physician is designated as his Primary Care Provider (PCP). Make sure that your child's physician's name or phone number appears on your card and /or the insurance company has been informed of your child's PCP name as of the date of service, OTHERWISE YOU ARE RESPONSIBLE FOR PAYMENT OF THE VISIT.

If your child's physician does not accept or participate in your insurance plan, payment in full is expected at the time of your child's visit.

If you participate in a HIGH DEDUCTIBLE HEALTH PLAN, you are required to PAY IN FULL THE ALLOWED AMOUNT ON YOUR INSURANCE UNTIL YOUR DEDUCTIBLE IS MET.

Co-payments are due AT THE TIME OF SERVICE and are collected at CHECK-IN at the front desk. THE PARENT, LEGAL GUARDIAN, AUTHORIZED RELATIVE OR OTHER AUTHORIZED ADULT WHO IS ACCOMPANYING THE CHILD IS RESPONSIBLE FOR PAYING THE CO-PAY ON THE DAY AND TIME OF SERVICE. COPAYMENTS MAY NOT BE WAIVED.

You are responsible for knowing what benefits and services your health insurance covers for your child. Insurance benefits VARY WIDELY. Not all services provided in the office are covered by every insurance plan. For example, some plans do not cover well child visits at all or have a limited maximum amount for well childcare per year or cover only immunizations required by the state. Please check with your insurance plan before scheduling annual health check-ups especially after the age of 4. NOTE: Some annual well child check-ups are covered once every 365 days whereas other health plans allow 1 well child check-up per calendar year.

This office does try to verify your child's insurance coverage and benefits several days in advance of your child's scheduled well child visit, but you are ultimately responsible for payment of services determined not to be covered by your plan.

You will be advised of any outstanding balances due when you CHECK IN AT THE FRONT desk for your child's visit. Payment of outstanding balances MUST BE ADDRESSED prior to your child's visit. Balances are billed immediately on receipt of your insurance plan's explanation of benefits (EOB) by the billing department. Your bill is due upon receipt of your bill by mail. Please contact the billing office at the number on your statement to discuss bills, balances and payment questions during office business hours.

There is a $35.00 fee for each check returned for NSF or any other reason AND NSF fee will need to be paid with cash or valid credit/debit card for any visits in the future.

As a courtesy to other families in the practice who may need appointments for sick children, please give at least 24-hour notice to the office when you will not be able to keep an appointment previously scheduled. Missing 3 scheduled appointments without prior notice to the office may be grounds for your child's dismissal from the practice.

• Immunization evaluation
• Age-appropriate preventative screening
• Proper weight, diet and exercise counseling
• Refills for chronic / pre-existing conditions

• Evaluation and treatment of any medical complaints or findings, including new medications or changes in treatment plans for a chronic / pre-existing condition.
• Treatment for any abnormalities discovered during the exam.

Depending on the severity of your medical needs, we may schedule an appointment at a later date for your preventative visit.

The provider may choose to address your medical needs today with your preventive visit. However, BOTH an office visit and preventative visit will be billed.

• I understand that if the provider discovers an abnormality during my preventative visit and additional treatment or evaluation is needed for this issue, an office visit will be billed as well as the preventative visit.
• I understand that if an office visit is billed, my responsibility for this service such as copays, deductibles or co-insurance will be owed.

I have read and understand the office financial policy and agree to comply and accept responsibility for any payment that becomes due as outlined.

2.2026

Consent For Care And Treatment: I understand that Patient, which may be defined as me, my child or a child for whom I have legal responsibility, needs medical care and treatment and I consent to such treatment at Mansfield Pediatrics. Treatment provided by medical providers, nurses and medical assistants at Mansfield Pediatrics may include evaluation and management, vaccinations, laboratory and other testing; routine medical, nursing and medical assistant care and procedures. I understand that photos and video of the patient may be taken in connection with such treatment and for operational, quality institution and agree that students may observe and participate in patient's care and treatment under appropriate supervision.

Patient Rights: I have been provided information regarding Patient Rights and Responsibilities. This information tells me how to register a complaint or grievance that I might have relating to Patient's care at Mansfield Pediatrics.

Communicable Disease Testing: I agree that is a Mansfield Pediatrics employee or provider is exposed to Patient's blood or other bodily fluid, pursuant to Texas law, Mansfield Pediatrics may test Patient to determine the presence of communicable diseases including Human Immunodeficiency Virus (HIV) and hepatitis. I understand that these test results will be kept confidential.

Text Messaging: I understand that Mansfield Pediatrics may, in its sole discretion, remove, retain or can provide notifications to my cell phone. These texts are Do Not Reply texts for informational purposes only and are not intended as a form of two-way communication. I acknowledge that standard text messaging rates and fees will apply, text messaging utilizes a public telephone network and full security is not guaranteed, and any person with access to my phone will be able to see these unless I take steps to protect my phone with a password or PIN. I hereby consent to Mansfield Pediatrics sending me such texts.

Telemedicine: I understand that video conferencing technology will be used and that such a consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. I understand that my healthcare information may be shared within Mansfield Pediatrics for scheduling and billing purposes. I understand that starting / connecting to secure Doxy.me platform will start with a text message or email link.

Notice of Privacy Practices: I acknowledge that I have received the Mansfield Pediatrics Notice of Privacy Practices. Any questions or concerns may be directed to Mansfield Pediatrics Privacy Office at the following email address: admin@mansfieldtxpediatrics.com.

Use and Disclosure of Information: I understand that Patient's medical records are confidential and cannot be disclosed without my written authorization except as authorized by law. Authorized disclosures are addressed in the Notice of Privacy Practices I have received. I understand that Patient's medical information includes past, present and future information and may include genetic testing/counseling, communicable disease information including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), records related to mental health treatment / psychiatric care and alcohol / substance abuse diagnosis or treatment (Medical information). I understand Mansfield Pediatrics must keep Patient's medical records for a time period required by law and then may dispose of them as permitted or required by law.

Consent for Electronic Sharing and Health Information Exchange: I authorize Mansfield Pediatrics to use Patient's Medical Information for Patient's treatment and related services. Unless I object below, I authorize Mansfield Pediatrics to release and sent Patient's Medical Information to Patient's non-Mansfield Pediatrics health care provider electronically and/or through a Health Information Exchange (HIE), an organization that

provides services to enable the electronic sharing of health-relating information. Medical Information disclosed pursuant to this authorization may be used for treatment, payment and operational purposes. The Medical Information disclosed may become a part of my non-Mansfield Pediatrics health care providers' medical records and may be re-disclosed by the recipient and no longer protected by state or federal privacy laws. I understand that if Patient is also a Patient at Mansfield Pediatrics, the Medical Information from records may also be released by my signing this authorization.

I understand I can change my mind and withdraw this authorization at any time but cannot take back information that has already been electronically shared. This consent is valid unless I have withdrawn it.

Mansfield Pediatrics follows the immunization recommendations of the American Academy of Pediatrics (AAP). We encourage all patients to remain up to date with vaccines in accordance with these guidelines. Our minimum immunization standards reflect both Texas daycare/school entry requirements and CDC recommendations.

The safety of our patients, especially infants and immuno-compromised children, is our highest priority. Children who are not vaccinated according to AAP guidelines are considered under-vaccinated, and our vaccination policy is enforced to reduce preventable health risks.

Families choosing to delay or modify vaccine schedules must meet the following minimum requirements

• By age 1 year, your child should have completed:
• 3 doses each: DTaP, HIB, inactivated Polio, Prevnar, Hepatitis B
• By age 2 years, your child should have completed:
• 1 dose of MMR (Measles, Mumps and Rubella), 1 dose of Varicella, 2 doses of Hepatitis A, and a booster dose of Prevnar, DTaP, and HIB.
• By age 6 years, your child should have completed
• Booster doses: MMR, Varicella, inactivated Polio, DTaP
• By age 12 years, your child should have completed:
• 1 dose each: Meningococcal Meningitis vaccine, Tdap
• By age 16 years, your child should have completed:
• 1 dose of HPV

Recommended but not required vaccinations:

• Immunizations for Certain High-Risk Groups
• Respiratory syncytial virus
• Meningococcal ACWY at age 16-18
• Meningococcal B at age 16-18
• Immunizations Based on Shared Clinical Decision-Making
• Rotavirus
• Influenza
• COVID-19

Mansfield Pediatrics will continue to care for new and established patients with legitimate medical contraindications or documented adverse reactions to vaccines. Our providers will create individualized plans in these cases.

I acknowledge that this policy has been discussed with me, and a copy will be added to my child's chart.

I hereby authorize my child's former physician:

To release the specified information below from the medical record of

Information may be released to the following party(s):

Mansfield Pediatrics
1825 Cannon Drive
Mansfield, TX 76063
(817) 453-7770 Fax (817) 453-7703
**We have EPIC EMR**
**NO CD'S PLEASE **

• I understand that my records are confidential and cannot be disclosed without my written authorization, except otherwise provided for by law.
• I also understand that records pertaining to the diagnosis and/or treatment of HIV testing, AIDS, psychiatric illness, alcohol or chemical dependency will not be released unless I have given my specific consent to release this information as indicated above.
• I also understand that I may revoke this authorization at any time except that action has been taken in reliance upon it. I understand that a photocopy or facsimile of this authorization is valid as the original.

Confidentiality notice: This message is intended only for the use of the individual or entity to which it is addressed and contains information that is legally privileged and confidential. If the reader of this message is not the intended recipient or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any use, dissemination, disclosure, or copying of this communication is strictly prohibited. If you have received this in error, please notify us immediately by telephone at the number listed above. 02/26

A parent, legal guardian or managing conservator must sign this form if the client is younger than 18 years of age.

The Texas Immunization Registry (ImmTrac2) is a free service of the Texas Department of State Health Services (DSHS). The Texas Immunization Registry is a secure and confidential service that consolidates and stores your child's (younger than 18 years of age) immunization records. With your consent, your child's immunization information will be included in the Texas Immunization Registry. Doctors, public health departments, schools, and other authorized professionals can access your child's immunization history to ensure that important vaccines are not missed. Visit Texas Health and Safety Code Sec. 161.007 (d) at statutes.capitol.texas.gov/Docs/HS/htm/HS.161.htm#161.007 for more information.

I understand that, by granting the consent below, I am authorizing release of the child's immunization information to DSHS and I further understand that DSHS will include this information in the Texas Immunization Registry. Once in the Texas Immunization Registry, the child's immunization information may by law be accessed by a public health district or local health department, for public health purposes within their areas of jurisdiction, a physician, or other health care provider legally authorized to administer vaccines, for treating the child as a patient, a state agency having legal custody of the child, a school or child-care facility in which the child is enrolled, and a payor, currently authorized by the Texas Department of Insurance to operate in Texas, regarding coverage for the child. I understand that I may withdraw this consent at any time by submitting a completed Withdrawal of Consent Form in writing to the Texas Department of State Health Services, Texas Immunization Registry.

State law permits the inclusion of immunization records for First Responders and their immediate family members in the Texas Immunization Registry. A "First Responder" is defined as a public safety employee or volunteer whose duties include responding rapidly to an emergency. An "immediate family member" is defined as a parent, spouse, child, or sibling who resides in the same household as the First Responder. Visit Texas Health and Safety Code Sec. 161.00705 at statutes.capitol.texas.gov/Docs/HS/htm/HS.161.htm#161.00705 for more information.

Please mark the box below to indicate whether your child is an Immediate Family Member of a First Responder.

By my signature below, I GRANT consent for registration. I wish to INCLUDE my child's information in the Texas Immunization Registry.

Parent, legal guardian, or managing conservator:

Privacy Notification: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. Visit dshs.state.tx.us/sites/default/files/hipaa/docs/DSHS-NPP-English-5-1-2022.pdf for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)

PROVIDERS REGISTERED WITH the Texas Immunization Registry: Please enter client information in the Texas Immunization Registry and affirm that consent has been granted. DO NOT fax to the Texas Immunization Registry. Retain this form in your client's record.

Questions? Tel: 800-252-9152 Fax: 512-776-7790 dshs.texas.gov/immunizations Texas Department of State Health Services Immunization Section Texas Immunization Registry - MC 1946 P. O. Box 149347 Austin, TX 78714-9347

Texas Department of State Health Services Immunization Section

Stock No. F11-11936 Rev. 02/2026

I understand that MANSFIELD PEDIATRICS, PLLC is offering me the opportunity to connect by telephone or through Children's Health, MyChart, a HIPAA compliant telemedicine platform, with one of my child's healthcare providers.

I understand that the purpose of this service is to seek medical advice and guidance for my child, who is not experiencing a life-threatening emergency. I understand that if at any time I feel I cannot wait for a visit, or if my child's condition becomes an emergency, I will call 911 and/or seek emergency medical care.

I understand that telemedicine involves the use of video communication and other technologies by a healthcare provider at a remote location to deliver services to a patient at another location. I understand that, unlike an in-person consultation, the provider will not be able to use senses such as touch or smell to assess my child's condition, nor will the provider be able to perform physical examinations, testing, or use diagnostic instruments.

I understand that telemedicine has limitations, which include, but are not limited to:

• Interruption or disconnection of audio/video resulting in incomplete or delayed assessment
• Delays in care caused by equipment or communication failures
• Inadequate video resolution leading to incomplete assessment
• Incomplete communication of medical history that may result in adverse drug interactions, allergic reactions, or other complications
• Potential overtreatment of viral conditions with antibiotics

In addition, I understand that the remote provider does not have the opportunity to evaluate my child in person and must rely on information provided by me, my child, or the on-site provider (if applicable). I acknowledge that the provider cannot be responsible for recommendations or decisions made based on incomplete or inaccurate information provided by me or others.

I understand that, just as with an in-person visit, I will be financially responsible for any charges associated with the telemedicine visit. I understand that my insurance plan may or may not cover telemedicine services.

My child and I had the opportunity to review this information before any payment was collected. By signing this form, I indicate that I have chosen to proceed with a telemedicine visit for my child.

I understand that the remote provider is a provider at MANSFIELD PEDIATRICS, PLLC. The clinic will maintain a record of the telemedicine visit in my child's medical chart, which I can access through the patient portal.

I consent to the healthcare provider with whom I am connected to providing healthcare services to my child via telemedicine. Unless this consent is revoked by me, it remains in effect, and the physician may provide telemedicine services without requiring a new consent form for each visit. By signing below, I certify that I have the legal authority to consent to medical treatment for the minor patient named.