Patient Name*

DOB*

Sex*

Preferred Language*

Ethnicity*

Race*

Who does patient live with*

Mothers Name*

Mothers DOB*

Primary#*

Email*

Address*

Fathers Name*

Fathers DOB*

Primary#*

Email*

Address*

LEGAL GUARDIAN OTHER THAN BIOLOGICAL PARENT MUST HAVE LEGAL DOCUMENTATION SHOWING GUARDIANSHIP

Name

DOB

Relationship

Email

Phone#

Address

Custody

Full

Temporary

Are parents separated?

Yes

No

Are there any legal restrictions that would restrict the non-custodial parent from consenting to medical treatment for the child or from obtaining information about the child’s medical treatment?

Yes

No

If so, please provide a copy of any legal paperwork that supports that restriction. *

THE FOLLOWING LISTED HAVE CONSENT TO BRING MY CHILD TO NUBY PEDIATRICS TO DISCUSS CARE AND TREATMENT.

Name

Relationship

Phone #

Name

Relationship

Phone #

EMERGENCY CONTACTS OTHER THAN PARENTS OR LEGAL GUARDIANS

Name

Relationship

Phone #

Name

Relationship

Phone #

Insurance Information

Patient is SELF PAY

By initialing here, I agree to call the office before appointment to let us know that patient is now self-pay.

Primary insurance name*

Insurance ID*

Group #*

Subscriber*

Subscriber DOB*

Relationship to patient*

Secondary insurance name

Insurance ID

Group #

Subscriber

Subscriber DOB

Relationship to patient

Please remember to provide a copy of your insurance card, so we can have an up-to-date copy for our records.

OFFICE POLICIES

Please read the following carefully and initial in spaces provided

It is the parent’s responsibility to provide the correct and current insurance policy(s) prior to the child’s appointment, if we are unable to verify insurance coverage at the date of service, you will be responsible for payment at that time as we do not backdate to bill claims.

Initials

All professional services rendered are charged to the patient and are due at the time of service, unless other arrangements have been made in advance with our billing manager. Balances that remain on your account more than 30 days are subject to further administrative/processing fees. Balances over 90 days are subject to reporting to a collection agency and the additional cost associated with the collection and or legal fees. A separate policy agreement will require your signature to ensure the understanding of our billing policy.

Initials*

Medical records can now be accessed through the patient portal via our website. If you choose to pick up a physical copy of your records, there will be a $25 charge. There will be no fee for records transferred to a physician for continuation of care.

Initials*

Because of the significant demand for ADHD/ADD appointments, we have developed a strict scheduling policy. If your child is scheduled for one of those appointments and are needing to cancel, please inform our office so we can cancel and have an available spot open for a new patient. Please contact our office at least 1 week prior to needing a refill(s) for ADHD/ADD medications.

Initials*

We are now going paperless. When coming into your appointment for a well visit, you’re usually given an ASQ depending on the age of your child. NOW, we are using a program called CHADIS. With that program you will be able to fill it out electronically on your own device. You will present your phone to the front desk, and they will scan a QR-Code for you, and you will complete the steps from there. If you are there for a behavior/mood visit, there are surveys that require the patient 12 yrs. + to complete themselves. By initialing here, you authorize to send that survey to patient’s phone to complete.

Initials*

Please provide the cell phone number of the patient*

We have a 15 minute grace period after your scheduled appointment. After that you will be asked to reschedule. If you have private insurance or are self-pay, you will be charged a $100 no-show fee.
Please inform us of your cancellation 24 hours in advance to avoid this fee.
*No-shows consist of same day cancellations, no-calls, and being more than 15 minutes late to your appt.
After 2 no-shows, patient and siblings will be dismissed from the clinic and will receive a certified letter. 1 no-show of a behavioral visit will result in being dismissed from the behavior clinic.

Initials*

PEDIATRIC HEALTH HISTORY FORM FOR INITIAL VISIT

Child's name*

DOB*

Age*

Your name*

Relationship to child*

Prior PCP*

Referred to us by*

Do you have any specific concerns to address at today’s visit?*

Pregnancy/Neonatal Period

Where is your child born

Is this your child by:

Birth

Adoption

Stepchild

Other

Please indicate any medical problems during pregnancy:

None

Specify

Delivered by

Vaginal Birth

C-Section

If by C-Section why?

Was your child pre-term?

No

Yes

Born at how many weeks?

Birth weight

Birth length

Any other problems as a newborn

Infancy/Childhood/Adolescence

Has your child ever been treated for or diagnosed with:(please explain)

Allergies-Seasonal

Allergies-Food

Allergies-Insects

Asthma or reactive airway Disease

Bronchitis or Pneumonia

Bronchiolitis (RSV or Non-RSV)

Wheezing

Recurrent ear or throat infections

Recurrent skin infections abscesses

Urinary Tract Infections

Anemia

anemia text*

Broken bones or severe sprains

Colic/GERD/Reflux

Genetic syndrome

Seizures

Has your child ever been hospitalized?

Yes

No

If yes Why?

Has your child had surgery?

Yes

No

If yes, why?

Please list any specialists your child is treated by and why

Medications

Allergies or reactions to medications or vaccines?

Current medications, vitamins or herbal supplements

Development/Nutrition

At what age did your child:

Roll over

Smile

Sit alone

Walk alone

Say words

Toilet train (day)

1st priod (girls)

Was your child breastfed?

Yes

How long?

No

Current milk intake:

Type:

Amt

oz/day

Family History

Do any family members have any of the following conditions? If so, mark the box for condition and which family member is affected.

Mom's height

Dad's height

Epilepsy

ADD/ADHD

Yes

Autism/Sensory

Yes

Learning Problems/ Dyslexia

Yes

Mental Retardation

Yes

Depression/Anxiety/Mood Problems

Yes

Any other chronic medical conditions

Yes

Family history

Social History

Who lives in the household with the child?

Name

Mom/Parent 1

Dad/Parent 2

Sibling 1

Sibling 2

Sibling 3

Sibling 4

Age

Mom/Parent 1

Dad/Parent 2

Sibling 1

Sibling 2

Sibling 3

Sibling 4

Health

Mom/Parent 1

Dad/Parent 2

Sibling 1

Sibling 2

Sibling 3

Sibling 4

Other (Please explain)

Child’s Parents are:

Married

Not Married

Divorced

Separated

Widowed

If divorced or separated, when?

Type of custody arrangements

Mothers occupation

Mothers Employer

Fathers Occupation

Fathers Employer

Childcare situation:

Parents

Other family

Who?

Daycare

Mothers day out

Babysitter/nanny

Days per week in childcare (not with parents)

Environmental Exposures

Is your child around anyone who smokes?

Yes

No

If yes, who smokes?

Did you know that children whose mother smokes are 60% more likely to smoke as adults? Would you like information on quitting smoking?

Info about smoke Yes

Info about smoke No

Are there any pets in the home?

Yes

No

If yes, what type? How many? Are they inside or outside pets?

Is violence at home a concern?

Yes

No

Are there guns at the home?

Yes

No

Are guns kept locked and store separately from ammunition?

Yes

No

Do you have any concerns about lead exposure? (old home, plumbing, peeling paint)

Yes

No

School History

Does/did your child attend preschool?

Yes

No

Is your child enrolled in school

Yes

No

Name of school

Current grade

Do you have any concerns about your child’s school performance?

Are there any concerns about your child’s relationship with teachers?

Yes

No

Are there any concerns about your child’s relationship with Peers?

Yes

No

If so, please explain

What is your childs favorite subject

What is your childs least favorite subject

Does your child read?

Yes

No

Do you read with your child?

Yes

No

What are your child’s hobbies or interests?

Does your child have any special talents?

Is your child involved in sports?

Yes

No

If so, which one(s)

How many times per week?

How long (Min)

Is your child at a competitive or select level

Health Habits

SLEEP

Hours per night

Naps

Any sleep problems?

DENTIST

Has your child visited the dentist?

Yes

No

Dentist how often?

Date of last visit

Any dental Problems?

Any orthodontics? (braces)

ELECTRONICS

TV - Hours per day?

Computers - Hours per day?

Video Games - Hours per day?

Is there anything else you feel would be helpful for us to know while caring for your child? *

PREVIOUS PEDIATRICIAN

Please name your previous pediatrician or name of the facility with phone number, address and fax number if available.

CURRENT MEDICATIONS

Please list all current medications with dosage and directions or check below if there are no current medications.

NO MEDICATIONS

1.

Name of medication

Dosage

Directions

2.

Name of medication

Dosage

Directions

3.

Name of medication

Dosage

Directions

4.

Name of medication

Dosage

Directions

5.

Name of medication

Dosage

Directions

6.

Name of medication

Dosage

Directions

7.

Name of medication

Dosage

Directions

8.

Name of medication

Dosage

Directions

9.

Name of medication

Dosage

Directions

10.

Name of medication

Dosage

Directions

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES/ USE AND DISCLOSURE FORM

Our Notice of Privacy Practices provides information about how we may use ancl disclose protected health information (PHI) about you.
We provide this form to comply with the Health Insurance Portability and Accountability Act (HIPAA).
Please review the Notice of Privacy Practices thoroughly before signing this acknowleclgement form. lfterms of our Notice change, a revised copy will be made available to you.

By signing this form, you acknowledge that our practice may use and disclose PHI about you for treatment, payment and healthcare operations.
You have the right to request that we restrict how PHI about you is used or disclosed for treatment, payment or healthcare operations.

Date

Printed Name of Patient

Legal Relationship to the Patient (If reauired)

We cannot discuss your health information with anyone other than yourself unless you authorize us to do so. Please list belcw names of the individuals you authorize our office to discuss care with.

I give you permission to share my health information with:

1. Name

Relationship

Phone #

2. Name

Relationship

Phone #

Consent to email or text for appointment reminders and other healthcare communication.

If you approve, we may contact you via email and/or text messaging to remind you of an appointment or provide general health reminders or information. I understand that once I have consented to receive communications via text or email, I still have the right to revoke the consent at any time.

The cell phone number I authorize lo receive text messages for a􀂋poinlment reminders and general health information is:

Please Initial:

The email address that I authorize to receive email messages for appointment reminders and general health information is:

Please initial

Or

I decline to receive communications via text.

I decline to receive communications via email.

Revocation - Use this area to document revocation of a previous form of communication.

I hereby revoke my request to receive future appointment reminders or heatthcare updates via text

I hereby revoke my request to receive future appointment reminders or heatthcare updates via email

Date requested

CONSENT FOR USE / DISCLOSURE OF HEALTH INFORMATION

Patient's Name*

Patient's Date of Birth*

Patient's SS Number*

Notice to Patient:
By signing this form, you grant us consent to use and disclose your protected health care information for the purposes of treatment, various activities associated with payment and health care operations. Our Notice of Privacy Practices provides more details on our treatment, payment activities and health care operations. If there is not a copy of the Notice accompanying this Consent form, please ask for one. We encourage you to read it since it provides details on how information about you may be used and/or disclosed and describes certain rights you have regarding your health care information.
As stated in our Notice of Privacy Practices, we reserve the right to change our privacy practices. If we should do so, we will issue a revised Notice. Since revisions may apply to your health care information, you have a right to receive a copy by contacting our Privacy Officer.

You have the right to revoke your Consent by giving written notice to our Privacy Officer. The revocation will not affect actions that were already taken in reliance upon this Consent. You should also understand that if you revoke this Consent we may decline to treat you.

You are entitled to a copy of this Consent Form after you have signed it.

(To Be Completed by Patient or Patient’s Representative)
I have read the contents of this Consent Form and the Notice of Privacy Practices. I understand that I am giving you my consent to use and disclose my health care information to carry out treatment, payment activities and health care operations.

Patient name*

Date*

Printed Name of Patient’s Representative *

Relationship to Patient *

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

TO REQUEST RELEASE OF MEDICAL INFORMATION PLEASE COMPLETE AND SIGN BELOW

I hereby voluntarily authorize the disclosure of information from my health record.

Patient Name

Patient DOB

Info requested

Purpose of release:

TRANSFER OF CARE

OTHER

From

Phone #

Fax #

The information is to be provided to:

Name of person/organization/facility:

Address

Phone #

Fax #

1. I understand that this authorization will expire on one year from today’s date

Today's date

2. I understand that I may revoke this authorization (except to the extent that action was already taken in reliance on this signed authorization) at any time by notifying NUBY PEDIATRICS in writing.
3. I understand that I can refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment, payment, or my eligibility of benefits (if applicable)
4. I may inspect or copy any information used or disclosed under this agreement.
5. I understand that if the person or organization that receives the information is not a health care provider or plan covered by the federal privacy law and regulations, the information described above may be redisclosed and would no longer be protected by these regulations.

Printed name of Patient’s representative

Relationship to patient

You have a right to receive a copy of this form!

Email concent

VERY IMPORTANT! PLEASE READ!

• HIP AA stands for the Health Insurance Portability and Accountability Act
• HIPAA was passed by the U.S. government in 1996 ln order to establish privacy and security protections for health information
• Information stored on our computers is encrypted
• Most popular email services (ex. Hotmail, Gmail, Yahoo) do not utilize encrypted email
• When we send you an email, or you send us an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is transmitted over the Internet. In addition, once the email is received by you, someone may be able to access your email account and read it.
• Email is a very popular and convenient way to communicate for a lot of people, so in their latest modification to the HIPAA act, the federal government provided guidance on email and HIPAA
• The information is available in a pdf (page 5634) on the U.S. Department of Health and Human Services website
• The guidelines state that if a patient has been made aware of the risks of unencrypted email, and that same patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email

OPTION 1-ALLOW UNENCRYPTED EMAIL
I understand the risks of unencrypted email and do hereby give permission to the Nuby Pediatrics to send me personal health information via unencrypted email

Allow date

Printed name

Please print email address

OPTION 2 - DO NOT ALLOW UN ENCRYPTED EMAIL
I do not wish to receive personal health information via email

Date

Printed name

Patient Portal Consent

Nuby Pediatrics is now offering a secure HIPAA compliant communication tool as a courtesy to our patients.
It is an optional service, and we reserve the right to suspend or terminate it at any time. We will alert you to any changes as promptly as possible.
This form is intended to inform you of the facts and risks surrounding the use of the web portal.
By signing below, you confirm that you have read, understand and agree to comply with our procedures and guidelines for using the patient portal.
You also agree not to hold Nuby Pediatrics or any of the staff liable for network infractions beyond their control.
Privacy and security the web portal or webpage has secure connection with our clinic that uses encryption to keep unauthorized persons from being able to access and read your health information or your communication to us.
To help ensure that it remains secure, we need to have your password secure so only you or someone authorized by you can gain access to patient information.
If you think someone has learned your password, immediately go to your portal account and change it. Your email is confidential and protected information.
With our best effort, we will protect this Information with any third-party. All access to our internal network and our electronic medical records are password protected.
Our staff are Instructed to log off their workstations when not physically present. Like phone communications, messages may be read and addressed by different Nuby Pediatrics staff members.

Confidential Email*

Your Portal login vill go to this address

DOB*

Patient's Printed Name*

DOB*

Name of guardian/parent requesting access*

E-Signature

Please sign electronically below.

Patient Information

LEGAL GUARDIAN OTHER THAN BIOLOGICAL PARENT ***MUST HAVE LEGAL DOCUMENTATION SHOWING GUARDIANSHIP***

THE FOLLOWING LISTED HAVE CONSENT TO BRING MY CHILD TO NUBY PEDIATRICS TO DISCUSS CARE AND TREATMENT.

EMERGENCY CONTACTS OTHER THAN PARENTS OR LEGAL GUARDIANS

Insurance Information

OFFICE POLICIES

PEDIATRIC HEALTH HISTORY FORM FOR INITIAL VISIT

Infancy/Childhood/Adolescence

Development/Nutrition

Family History

Family history

Social History

Environmental Exposures

School History

Health Habits

PREVIOUS PEDIATRICIAN

CURRENT MEDICATIONS

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES/ USE AND DISCLOSURE FORM

Or

CONSENT FOR USE / DISCLOSURE OF HEALTH INFORMATION

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

The information is to be provided to:

Email concent

Patient Portal Consent

E-Signature

LEGAL GUARDIAN OTHER THAN BIOLOGICAL PARENT MUST HAVE LEGAL DOCUMENTATION SHOWING GUARDIANSHIP