2025 Adult Patient Registration

2025 Adult Patient Registration
Demographics
Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Sex*

FemaleMale
Nickname
Phone Number*
Please enter a valid phone number.
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Insurance Information

You will be asked to present your current insurance card and ID at every visit
Primary Insurance Carrier Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security number
Relationship to Patient
Insurance Company*
Member ID
Group Number
Copay Amount
High deductible plan

YesNo
Policy Active Date

MonthDayYear
Date
Front of Insurance Card

Cancelof
Back of Insurnace Card

Cancelof
Secondary Insurance*

YesNo
Secondary Insurance Carrier Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Relationship to Patient*
Insurance Company*
Member ID
Group Number
High deductible plan

YesNo
Copay Amount
Policy Active Date

MonthDayYear
Date
Front of Insurance Card

Cancelof
Back of Insurnace Card

Cancelof
Billing Account Information:

Please list both parents/legal Guardian
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Date of Birth:

MonthDayYear
Date
Email
example@example.com
Relationship to Patient
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Place of Employment
Occupation
Social Security Number
This is for billing and referral purpose

Communication Release of Information
The Privacy Rule generally requires healthcare providers to take reasonable steps to minimize the Protected Health Information (PHI) requests, usage, and disclosure for only what is required to meet the intended need. These provisions do not apply to uses or disclosures made pursuant to an authorization request by the individual.

NOTE: Uses and disclosures for reasons other than treatment, payment, or operations may be permitted without prior consent in a medical emergency
Please select one below:*

DO NOT PROVIDE health information (regarding appointments, medication, and test results) or account information to anyone but me.I give permission to the individual list below to receive my health information
Authorized Representatives
Name

First NameLast Name
Relationship
What information to share

AppointmentsBillingTest ResultsDiscuss my condition and treatment
Name

First NameLast Name
Relationship
What information to share

AppointmentsBillingTest ResultsDiscuss my condition and treatment
Signature

Clear
You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Date*

MonthDayYear
Date
Print full name

First NameLast Name
Office Policies

To received the full copy of Limestone Pediatrics office policies please request a copy in office or visit our website www.Limestonepeds.com
Appointments

At Limestone, we feel strongly about children having routine check-ups. These visits allow us to monitor growth, developmental, behavioral and academic issues so that we can identify them early, intervene, and treat them effectively. Per the American Academy of Pediatrics, children should receive preventative care at the following ages:

1month of age, 2mo, 4mo, 6mo, 9mo, 12mo, 15mo, 18mo, 24mo, 30mo, then yearly from 3-22 years of age.

We expect parents to follow these guidelines so that we can provide quality healthcare to our patients. Failure to do so may result in our being discharged from our practice. Documents and school forms will not be completed for patients who are behind on well checks. Physicals for 3-22 years are done on a yearly basis most insurance requires these to be done 1 year and a day from the last physical. The office will send out reminders when it is time to schedule for an upcoming physical. If physicals are not kept up to date after several attempts by our office to schedule, our Providers may dismiss the family from the practice.

Difference between Well Child Physical and Office Visits

Preventive visits and office visits may seem similar, but there is a difference. Knowing the difference can help ease any confusion.

You schedule well child exams and wellness exams to help prevent or detect any health concerns. This is also known as your annual wellness exam or annual health maintenance exam.

Confusion arises when you want to discuss or receive treatment for a new or existing condition that requires action at your annual checkup. This is where a preventive visit can become an office visit, and your bill can be impacted.

Preventive Visit	Office Visit
Complete physical exam (annual health maintenance exam)	Diagnosing and monitoring specific medical conditions
A thorough review of medical history, general health and well-being	Addressing medical concerns and treatment plans
Developmental screenings* Evaluation of future risks	Medication refills
Vaccination review and update	Addressing new or worsening symptoms
	Specialist referrals Testing/lab results

Depending on benefits an office visit can result in additional costs

*Screenings

We follow the AAP (American Academy of Pediatrics) recommended screenings to be performed at certain visits. Insurance companies also encourage us to administer these screenings at visits, even though some of them will pass the cost of the screenings to the patient rather than covering themselves. The office does not know the cost of these screenings as this varies between insurance plans.

If during a routine preventative visit, you and/or your provider discuss the management of your child’s existing and/or any new medical problems, your insurance will be billed for a separate office visit. The additional office visit charge may not be considered by your insurance company to be part of the annual check-up. We are required to report to your insurance company everything that is done in the visit by listing all current and new diagnoses discussed. Your insurance company will determine whether to add a copay on to the well visit.

If we do not tell the insurance company everything that is done during the visit we could lose our contract with them. We cannot waive a copay as the insurance company considers that to be fraudulent on our part.

Signature*

Clear
You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Date*

MonthDayYear
Date
Please type full name of signee

First NameLast Name
Weekend and Federal Holidays
When you are seen for a weekend visit or a visit that is also a Federal holiday per your insurance we must add the extended code, depending on your insurance plan you may have a balance due for the visit. We understand that the office is routinely your insurance advises we can bill these codes.
Mutual Respect of time and After-Hours Nurse Calls
Providers at Limestone Pediatrics strive to stay on schedule. Although there can be emergencies that prevent us from running on time, we pledge to provide quality care with minimal waiting time to the best of our ability. We have many patients in our practice, and all are important to us. Missing an appointment without giving prior notice to the practice deprives other patients of the chance to take that appointment slot.

Therefore, we require no less than 24 hours’ notice for all cancellations of pre-scheduled visits. If you cannot notify our office promptly, a no-show fee of $35 will be charged to the patient’s account and must be paid before rescheduling.

To respect your time, we make the following requests:
- Arrive early or on time for your appointments. If you arrive 10 or more minutes late, you will be asked to reschedule.
- If you plan on having additional children seen at your appointment, please let us know in advance so we can better accommodate your family.
- If you are running late, please call the office. We may be able to accommodate you with advanced notice.
- Three (3) “no-show” appointments without notice from you in one year may result in dismissal from our practice.
- New patients who do not show up without notice to their first appointment may not be scheduled for additional appointments.
If you are more than 10 minutes late for an appointment this appointment will need to be rescheduled for a later date or time and incur a missed appointment fee of $35.

After-Hours Nurse Calls

After hours, we offer a telephone triage consultation service that puts you in touch with a pediatric-trained triage nurse. Families will be charged for each triage call made ($16). There are exceptions for advice given for infants less than 90 days old or where recommendations are given to immediately be seen by a healthcare provider. Additionally, if a provider speaks with a parent directly after hours or on the weekend, the call will be billed to your health insurance.
Please type full name of signee

First NameLast Name
Signature*

Clear
You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Date*

MonthDayYear
Date
Kentucky Immunization and Document Exchange
Limestone Pediatrics participates with the Kentucky Immunization Registry and Kentucky clinical document exchange. Vaccines given to all patients in our office are entered into the KYIR (Kentucky immunization registry) system, a service of the Kentucky Department for Public Health that allows schools, individuals, parents, and legal guardians to access official immunization records.

Kentucky Clinical Document Exchange allows different healthcare organizations to exchange patient records for treatment purposes. For example, your child is seen by a specialist or in the Emergency Room. That provider can quickly access your child’s records to find out what medications your child is taking, or that they have a medication allergy, demographics, diagnoses, or medications.

Only providers at healthcare organizations that participate in Clinical Document Exchange through the Interoperability Framework Care Quality can retrieve your records. They may retrieve your records for treatment purposes only.

By signing below, you permit Limestone Pediatrics to share your information with the above-listed organizations.
Please type full name of signee

First NameLast Name
Signature*

Clear
You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Date*

MonthDayYear
Date
The full copy of Limestone Pediatrics office policy can be found on our website www.limestonepeds.com or you may request a paper copy at any time.
Should be Empty:

2025 Adult Patient Registration

Demographics

Insurance Information

Billing Account Information:

Communication Release of Information

Authorized Representatives

Office Policies

Appointments

Weekend and Federal Holidays

Mutual Respect of time and After-Hours Nurse Calls

Kentucky Immunization and Document Exchange