Adult Patient Registration

Adult Patient Registration
Name*

First NameLast Name
Sex:*

MaleFemale
Date of Birth*

MonthDayYear
Date
Ethnicity*
Race:*

WhiteAmerican Indian/Alaskan NativeAsianBlack/African AmericanNative HI/Pacific ISPrefer not to answerOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent Information:
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Relationship to Patient*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place of Employment*
Occupation*
Social Security Number *
This is for billing purpose
Parent Information:
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to Patient
Different Address*

YesNo
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Place of Employment
Occupation
Social Security Number
This is for billing purpose
Insurance Information
Insurance Company Name:*
Member ID:*
Group Number:*
Copay Amount:*
Policy Holders Name*

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Date
Relationship to Patient:*
Date Policy Active*

MonthDayYear
Date
Please Attach the front and back of the insurance card

Cancelof
Secondary Insurance*

YesNo
Insurance Company Name:*
Member ID:*
Group Number:*
Copay Amount:*
Date of Birth*

MonthDayYear
Date
Policy Holders Name*

First NameLast Name
Relationship to Patient:*
Please Attach the front and back of the insurance card

Cancelof
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 receive my health information regarding normal test results in a voice mail message.
Authorized Representatives
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship*
I give to receive the following PHI elements as specified below:*

AppointmentsBillingTest ResultsDiscuss my condition and treatment
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship*
I give to receive the following PHI elements as specified below:*

AppointmentsBillingTest ResultsDiscuss my condition and treatment
Signature*

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Date

MonthDayYear
Date
Patient Communication Preference
I agree to allow Poole and Thomas Pediatrics to contact me in the following methods regarding my private health information, evaluation, and treatment.

Contact Method*

	Yes	Phone Number	Okay to leave message?
Cell Phone
Home Phone
Text Message
Portal

Portal

Adult patients will need to set up access to portal as parents no longer have access once patient is 18yrs old.
Poole and Thomas require each person to have a portal as this is a communication tool our office uses for medication refills,.
Do you currently have a portal*

YesNo
Please enter the phone number you would like to use as a log in.
Please enter a valid phone number.
By my signature below I acknowledge that I have read and understand the information provided on this consent form. I understand the risk associated with the different methods of communication, especially e-mail and texting, and consent to the conditions, restrictions, and patient responsibilities as well as any other instruction that Poole and Thomas Pediatrics may impose.
Signature*

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

MonthDayYear
Date
Financial Policy
Poole and Thomas Pediatrics, PLC

FINANCIAL POLICY

EFFECTIVE January 1, 2024

Thank you for choosing and entrusting Poole and Thomas Pediatrics for your child(ren)’s care. Drs. Poole, Thomas, Crowley and Goodsell are dedicated to providing excellent care to your children at a fair and reasonable rate. In order to provide this care, we have adopted the following financial policy. We recognize that the cost of health insurance has increased; unfortunately, our costs to provide that care have risen significantly as well.

It is our goal to eliminate future misunderstandings in regards to our billing and payment policies. Our staff will be happy to discuss any fees or financial issues in advance or at the time of your visit. We participate with most major insurance plans. While we will work with you to submit your claims to your insurance company, please note that ultimately your insurance is a contract between you and your insurance carrier. Each insurance policy is individual and it is your responsibility to understand your benefits, eligibility dates, and what is and is not covered by your plan. If claims are not paid within 90 days, the unpaid balance becomes the responsibility of the parent/guardian. We will make every effort to work with you to file insurance claims and resolve any outstanding balances in a timely manner.

Please be aware that you MUST provide updated demographic (address and phone numbers) and insurance information to our office. Up-to-date information is needed for both parents. We must have a current copy of your insurance card and ID on file at all times. If your insurance changes, it is your responsibility to let us know as soon as possible, along with the effective dates of your new policy. If previous visits need to be re-filed to a different insurance, you must notify us immediately due to Timely Filing requirements by your insurance company. If you do not provide us with the correct insurance information at the time of the change, then your claims may be denied due to timely filing by your insurance and those claims would then become your financial responsibility. You will also be responsible for any denied charges due to incorrect information.

Co-pays, Co-insurance and Deductibles will be expected at time of service. Private Pay Patients are expected to pay in full at the time of service. If there is an outstanding balance on your account and you are being seen in the office, the balance will be required to be paid in FULL at time of service. NO EXCEPTIONS. In the event of a separation/divorce, the parent bringing the child for an appointment is responsible for the co-pay or balance, which is due during that visit to our office. If one parent specifically is responsible for medical bills, we must be notified by both parties. Whichever parent/guardian signs this form, you will be held responsible for any amount owed and it will be your responsibility to collect from the other party.

Please note, if your child is being seen for a Well Child Check and you have other concerns that are not related to routine wellness care, these may generate other charges to your insurance. A listing of potential charges can be found in our office and per request in the portal.

No-show or late cancellation fee: A fee of $35 will be charged to patients who do not provide 24-hour notification to cancel an appointment or for patients who miss their scheduled same-day appointment.

After 3 no-shows or late canceled appointments, your family may be discharged from the practice.

If a new patient misses their initial visit they may be dismissed from the practice.

Phone triage: 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.

Weekends and After-Hours visits: There is an additional fee for appointments on late evenings, weekends, and holidays that may or may not be covered by your insurance. Any unpaid charges will be your responsibility.

Payment: We accept cash, debit cards, Visa, MasterCard, Discover, Amex. We will not accept checks as a form of payment. Our staff or contracted billing company, PedsOne, may contact you at any of the numbers provided by you in an attempt to resolve any outstanding balances. All questions regarding visit-based billing can be answered by PedsOne at 866-371-6118.

We require that every family activates a portal account as this will be our way of appointment reminders, request for forms and many other features. Please email portal@ptpediatrics.com to set up.

You can expect to receive billing statements from our billing company (PedsOne), our vaccine supplier (Vaxcare), or directly from our office and payment is due within 30 days. If you have not made a payment within 30 days from receipt of the statement, you will receive a letter asking for payment. If we do not hear from you at that time, your account will be turned over to a professional collection agency. This will result in the termination of the physician/patient relationship.

Assignment of Benefits/Authorization: As parent or legal guardian, I authorize payment of medical benefits directly to Poole and Thomas Pediatrics, PLC for services rendered. I further agree to be fully responsible for all lawful debts incurred for these services.
Signature*

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Date

MonthDayYear
Date

Medical Records and Privacy Policy
At Poole and Thomas Pediatrics, we are committed to protecting the security and privacy of your child’s personal information. Medical records are the property of Poole and Thomas Pediatrics. These records are kept in a secure location and are accessed only for the purposes outlined by the Notice of Privacy Practices (Revised 9/23/13). Our revised Privacy Notice is available at www.ptpediatrics.com, or you may request a copy from our office. Records may be released or shared with other healthcare professionals for the treatment of your child. Patients are entitled to one free copy of their medical records only after an authorization for release is signed.

By signing below, I acknowledge that I have received Poole and Thomas Pediatrics Notice of Privacy Practices and consent to treat information. I understand that I can edit any of the terms below. I understand that PTP may call my home and place of employment for healthcare reasons, appointment reminders, to resolve billing issues, and may mail me information postcards to my home address. PTP may also mail bills to my mailing address.

I understand that PTP may leave messages on my answering machine regarding appointments and limited lab information.

I understand that PTP may use an email address or fax, provided by me to communicate appointment information, billing issues, immunization certificates, lab and test results, and other forms requested by the parent.

I authorize PTP to email or fax immunization certificates and/or school forms, or to mail to my home address provided.

I authorize PTP to discuss patient information with adults or other minors present during the visit regardless of whether I am present.

I understand that if I send a picture of myself or child(ren) PTP may display it within the office.
Signature*

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

MonthDayYear
Date
Should be Empty:

Adult Patient Registration

Parent Information:

Parent Information:

Insurance Information

COMMUNICATION RELEASE OF INFORMATION

Authorized Representatives

Patient Communication Preference

Portal

Financial Policy

Medical Records and Privacy Policy