NEW PATIENT INFORMATION

Nassau Bay Pediatrics, PA

2640 E. League City Parkway, STE 114. League City, TX 77573 Phone: 281-212-2400 Fax:281-212-2499
New Patient Information
Patient Name

First NameLast Name
Sex
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Mother

First NameLast Name
Parent/Guardian Date Of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Employment

Employer Name

Address

City/State/ZipPhone

Occupation
Father

First NameLast Name
Parent/Guardian Date Of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Employment

Employer Name

Address

City/State/ZipPhone

Occupation
Emergency Contact

Please add an Emergency Contact section in addition to the Mother and Father/Guardian information
Emergency Contact

First NameLast Name
Relationship
Contact Number
Format: (000) 000-0000.
Insurance Information

Please notify the clinic if there is a secondary payer
Insurance Company
Insurance ID
Policy Holder's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to Policy Holder
Insurance Card Front & Back

Please upload a clear image of the front & back of your insurance card
Cancelof
Insurance Coverage Acknowledgement Consent

By signing below, I acknowledge that I have read and received the insurance coverage acknowledgment consents. I understand that I will receive an emailed copy of all completed and signed forms for my records, and that a printed copy is available upon request.
Benefits available through your insurance company vary depending on your employer and individual coverage plan. Unfortunately, there is no uniform standard across insurance providers, which can make it difficult to know exactly what services your plan covers. To become an informed consumer, we strongly encourage you to review your benefits through your insurance company’s website, printed materials, and/or patient portal applications.

Nassau Bay Pediatrics makes every effort to verify insurance coverage prior to your visit; however, verification is not a guarantee of payment or coverage, and the information provided to us may be incomplete. Certain services that are medically recommended may not be considered covered services under the limits of your individual policy. Deductibles, copayments, and coinsurance amounts may change periodically—even with the same employer and insurance plan.

At the time of service, we will attempt to inform you of any non-covered services if that information is available to us. Any waiver provided is intended to notify you that certain charges may not be covered by your insurance and that you may be financially responsible for those services.
By signing any insurance-related waiver, you acknowledge understanding of your financial responsibility should your insurance carrier deny payment.
Thank you for allowing us to care for your family.

Yours truly,
Nassau Bay Pediatrics
By signing any insurance-related waiver, you acknowledge understanding of your financial responsibility should your insurance carrier deny payment.
Parent/Guardian Acknowledgment Name
Parent/Guardian Acknowledgment Signature

Parent/Guardian Acknowledgment
I hereby acknowledge that the information I have provided is accurate and complete to the best of my knowledge. I certify that I am the patient's legal parent and/or legal guardian and have the authority to complete and sign this form on the patient's behalf.
Parent/Guardian Acknowledgment Name
Parent/Guardian Acknowledgment Signature
Consent to Treatment & Acknowledgment of Financial Responsibility

By signing below, I acknowledge that I have read and received the Consent to Treatment & Acknowledgment of Financial Responsibility consents. I understand that I will receive an emailed copy of all completed and signed forms for my records, and that a printed copy is available upon request.
I hereby consent to medical treatment as deemed necessary for the care of the patient named above. This consent includes, but is not limited to, examinations, medications, laboratory testing, diagnostic procedures, and other medically appropriate services provided by the physician or their qualified designee.
- I accept financial responsibility for all services rendered and agree to pay all applicable copayments, deductibles, coinsurance, and outstanding balances at the time of service unless prior arrangements have been made.
- I understand that insurance coverage is a contract between myself and my insurance carrier. Nassau Bay Pediatrics, P.A. will assist in submitting claims to my insurance company; however, I acknowledge that I am ultimately responsible for payment of all charges not covered or paid by my insurance within a reasonable period of time.
- I authorize Nassau Bay Pediatrics, P.A. to release medical and billing information as required to my insurance carrier or third-party payer for the purpose of determining benefits and processing claims. I understand that such records may include information related to HIV/AIDS testing, substance use, and/or mental health services, when applicable.
- I also authorize Nassau Bay Pediatrics, P.A. to bill my insurance carrier or third-party payer directly and to receive payment for services provided.
I hereby consent to medical treatment and acknowledge receipt of the Consent to Treatment & Financial Responsibility forms.
Parent/Guardian Acknowledgment Name
Parent/Guardian Acknowledgment Signature
Privacy Policy Practices
Who Will Follow This Notice

Nassau Bay Pediatrics, P.A. provides healthcare to our patients in partnership with physicians, staff, and affiliated organizations. This Notice of Privacy Practices applies to:
• Any healthcare professional involved in your care

• All employees, staff members, and volunteers

• Any business associates or partners with whom we share protected health information

Our Pledge to You

We understand that medical information about you is personal. We are committed to protecting your medical and billing information. We maintain records of the care and services you receive to provide quality care and to comply with legal requirements. This notice applies to all records of your care maintained by Nassau Bay Pediatrics, P.A.
We are required by law to:
• Maintain the privacy of your protected health information (PHI)

• Provide you with this notice of our legal duties and privacy practices

• Follow the terms of this notice currently in effect

Changes to This Notice

We reserve the right to change our privacy practices at any time. Any changes will apply to protected health information we already have, as well as information received in the future. When significant changes are made, the updated notice will be posted in our office and available upon request.
You may request a copy of the current Notice of Privacy Practices at any time. You will be offered a copy at your first visit and asked to acknowledge receipt in writing.

How We May Use and Disclose Your Protected Health Information

We may use and disclose medical and billing information about you for:

• Treatment – such as sharing information with specialists involved in your care

• Payment – such as submitting claims to your insurance provider

• Healthcare Operations – such as quality improvement activities
We may also use or disclose your protected health information without prior authorization for certain purposes, including public health reporting, abuse or neglect reporting, health oversight activities, research, organ donation, workers’ compensation, emergencies, or when required by law (such as valid court orders or law enforcement requests).

We may contact you for appointment reminders or to inform you of treatment options or health-related services.

We may disclose information to a family member or friend involved in your care, or to disaster relief organizations, to help locate or notify family members of your condition.This notice describes how medical information about you may be used and disclosed, and how you can access this information. Please review it carefully.

If you have any questions, please contact our Privacy Officer using the contact information listed at the end of this notice.

Other Uses of Medical Information

Any uses or disclosures not covered by this notice will require your written authorization. You may revoke authorization at any time by submitting a written request.

Your Rights Regarding Your Health Information
You have the right to:

• Request access to or copies of your medical records (fees may apply)

• Request corrections to your records if you believe information is inaccurate or incomplete

• Request an accounting of disclosures (certain limitations apply)

• Request a paper copy of this notice if received electronically
• Request confidential communication of your medical information

• Request restrictions on certain uses or disclosures (approval not guaranteed)
All requests must be submitted in writing to our Privacy Officer.

Complaints

If you believe your privacy rights have been violated or disagree with a decision regarding your records, you may contact the following:

Daisy Martinez Privacy Officer Nassau Bay Pediatrics, P.A.

Phone: 281-212-2400
Lillie Rodriguez Privacy Officer Nassau Bay Pediatrics, P.A.

Phone: 281-212-2400

You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights.

Nassau Bay Pediatrics, P.A.

2640 E. League City Parkway, STE 114. League City, TX 77573
Phone: 281-212-2400 Fax:281-212-2499
Annette B. Ingraham, MD
Marissa S. Perona, MD
Acknowledgment of Receipt of Notice of Privacy Practices

By signing below, I acknowledge that I have read and received the Notice of Privacy Practices. I understand that I will receive an emailed copy of all completed and signed forms for my records, and that a printed copy is available upon request.
I acknowledge that I have received the Notice of Privacy Practices for Nassau Bay Pediatrics. I understand that this notice explains how my child's protected health information (PHI) may be used and disclosed, as well as my rights regarding that information.

I understand that:

- A copy of the Notice of Privacy Practices is available at our office upon request.
- A digital copy of the Notice of Privacy Practices will be emailed to me upon completion of these registration forms.

By signing below, I acknowledge receipt of the Notice of Privacy Practices. My signature does not indicate agreement with the contents, only that I have received the notice.
Parent/Guardian Acknowledgment Name
Parent/Guardian Acknowledgment Signature
Should be Empty:

Nassau Bay Pediatrics, PA

New Patient Information

Parent/Guardian Information

Emergency Contact

Insurance Information

Insurance Coverage Acknowledgement Consent

Parent/Guardian Acknowledgment

Consent to Treatment & Acknowledgment of Financial Responsibility

Privacy Policy Practices

Acknowledgment of Receipt of Notice of Privacy Practices