Tender Care Pediatrics PC

Tender Care Pediatrics PCNew Patient Registration FormToday’s Date:Patient’s Name: Pharmacy:FirstMiddleLast(Name and Location)Date of Birth: Gender: M/F(MM/DD/YYYY)Race:Ethnicity: Non-Hispanic/Hispanic or Latino/Declined(Circle one)African American/ Alaskan or American Indian/ Caucasian/ Asian/ Hawaiian or Pacific Island/Other/Declined (Circle one)Patients Primary Address:Email:Street & Apt #:City: State: Zip:Primary Phone: ()Secondary Phone: (-): (cell / landline)ok to text Y/N(Circle as applicable)-: (cell / landline)ok to text Y/N(Circle as applicable)Mother Or Primary Care Giver Information:MOM’s OR DAD’sMOM’s OR DAD’sState Relationship:First Name: Last Name: DOB:SSN:--Maiden Name:IF THE ADDRESS AND PHONE #S OF THE PRIMARY CARE GIVER ARE DIFFERENT FROM THE PATIENT,PLEASE FILL BELOW:Street & Apt #: City: State: Zip:Primary Phone: (Secondary Phone: ())-: (cell / landline): (cell / landline)Father Or Secondary Care Giver Information:ok to text Y/Nok to text Y/N(Circle as applicable)(Circle as applicable)State Relationship:First Name: Last Name: DOB:SSN:--Maiden Name:IF THE ADDRESS AND PHONE #S OF THE SECONDARY CARE GIVER ARE DIFFERENT FROM THE PATIENT,PLEASE FILL BELOW:Street & Apt #: City: State: Zip:Primary Phone: (Secondary Phone: ())-: (cell / landline): (cell / landline)Page 1ok to text Y/Nok to text Y/N(Circle as applicable)(Circle as applicable)

Tender Care Pediatrics PCInsurance Information:Primary Insurance Company:Copay:Insurance ID#: Group#:Policy Holder’s Name: Relationship:DOB:SSN:--Please list any siblings that share the above-mentioned information:1. First Name: Last Name: DB:2. First Name: Last Name: DB:3. First Name: Last Name: DB:4. First Name: Last Name: DB:Please list any siblings With Different Demographics/Parental/InsuranceInformation, please list below:1. First Name: Last Name: DB:2. First Name: Last Name: DB:3. First Name: Last Name: DB:4. First Name: Last Name: DB:Page 2

,,.Tender Care Pediatrics2322 New Road, Northfield, NJ 08225Phone: 609-641-0200Fax: 609-641-1304Consent for Treatment:I, the undersigned, hereby authorize Tender Care Pediatrics Physicians and fheir authorizeddesignates to perform lab test, administer immunizations and treatment as is necessary. I alsocertify that no guarantee or assurance has been made to the results that may be obtained.I understand and agree that health and accident insurance policies are an arrangement between aninsurance carrier and myself. Furthermore, I understand that this office will prepare anynecessary reports and forms to assist me in making collection from the insurance company andthat my amount authorized to be paid directly to this office will- be credited to my account uponreceipt. I permit this office to endorse remittances for the conveyance of credit to my account.However, I clearly understand and agree that all services rendefed to my children, spouse or selfor charged directly to me and that I am personally responsible for payment.Request for Payment of Benefits to Provider of Care:I authorize my Insurance Company/Insurance Administrator to pay by check, and for it to bemailed directly to: Tender Care Pediatrics P.C., 2322 New Road, Northfield, NJ 08225 theexpense benefits allowable and otherwi payable to me under my current policy, as paymenttowards the total charges for professional services rendered to my child/ward. I have agreed topay, in a current manner, any balance of said applicable charges. I agree that this office be givenpower of attorney to endorse/sign my name on any and all drafts for payment of my bill.Express Prior consent To Contact by Cell Phone:In order for Tender Care Pediatrics to service your account or to collect monies you may owe, Iagree Tender Care Pediatrics and/or authorized agents of Tender Care Pediatrics may contact meby telephone at any telephone number associated with your account, including mobil telephonenumbers, which could result in charges to me. I also agree to be contacted via text messages oremails. Methods of contact may include using prerecored/artifici;ll voice messages and/or use ofautomatic dialing deives, as appropriate.Consent for Treatment for Minor:r, the undersigned, hereby authorize Tender Care Pediatrics Physicians and whomever they maydesignate as her assistant(s) to perform lab test, administer immunizations and treatment as she·deems necessary to my (),-* :f1arent or Guardian's Signature:Pate:

Office Financial PolleyHere at Tender Care Pediatrics, we are doing .everything possible to hold.down the cost of medical care. You,the parent, can help a great deal by eliminating the need for us to charge and/or bill you for any reason. Thefollowing is an explanation of our Financial Polley. Please be sure to read the entire passage.If you are a recipient of Medicaid or any of the.-HMO products such as Horizon NJ Health, United CommunityPlan and Amerigroup, you must adhere to the policies of the Medicaid Program. The Medicaid Program andthe HMO products DO NOT cover any charges due to administrative fees. This includes any fees that areincurred from missed/late cancellation or rescheduling of appointments, print out of medical records and/orforms.Fees and Insurance CoverageAll patient payments will be collected before any services ar rendered. This includes, but is not limited toco-pays, patient balances related to administrative fees resulting from missed appointments, medical recordsand/or forms. Failure to pay your copay will result in an addi,lonal fee of 10 added to the balance. There isa 30 service charge for any returned checks./During your child's annual well visit a vision screening will be performed and could result in a small fee appliedby your insurance· compa.ny. If you refuse to have the screening performed, and require forms to be.filled outeither at the time of service or in the future, we.wlll indicate on any forms that the vision screening wasdeclined and it will become your responsibility to obtain your current results from your eye doctor or return toour office, where a copay may apply, to have the vision screening done. In addition, if you are here for apreventative care visit and receive any non-preventative care services such as prescriptions or counseling fornewly diagnosed illnesses or previously diagnosed chronic conditions a separate charge and/or copay,deductible or co-insurance may apply to the visit eyen If It was primarily a well child visit./Some appoint.ments may require additional services including but'not limited to wart treatments, hearingscreens, strep tests and urine cultures to be performed at the time of the appointment and may result inadditional fees aside from the office visit copay.Medical RecordsAny request for medical records REQUIRE a signed ·medical release form stating the authorization of releasefrom Tender Care Pediatrics to either a parent or the current physician's office. There is a 10 administrativefee for each requested record.Missed AppointmentsAny missed appointment, cancellation/rescheduling same day of appointments will result in a 50administrative fee per appointment. Three (3) or more appointments per family may result in a discharge from.,.the practice.have read the above office financial policy for Tender Care Pediatrics and I agree to the terms listed above.Signature: Patient Name: DOB:/Date:

Protected Health Information (PHI)/ HIPAA Patient Name (Print):Date,Due to recent implemented Federal Regulations the following public notice by Tender Care Pediatrics PCis effective as of November 1, 2011.The Tender Care Pediatrics PC is required to:1. · Maintain the privacy of your health information.2. Provide you with this notice as to what our legal duties and privacy practices·are with respect toinformation we collect aAndrews, Siennand maintain about you.3. Abide by the terms of this practice.4. Notify you if we are unable to agree to a requested restriction, and accommodate any reasonablerequest you may have to communicate health alternative means or alternative locations.Wewill not use or disclose your health information without your authorization, except as5.described in this notice.6. We will use and disclose your PHI in order to bill and collect payment for the services and itemsyou may have received from us. For example, we will contact your insurer to certify that you areeligible for benefits and we may provide your insurer with details regarding your treatment todetermine if your insurer will cover, or pay for, your treatment.WE ARE PERMI'ITED TO USE, AND MAY BE REQUIRED, TO DISCLOSE YOUR PHIUNDER SPECIAL CIRCUSTANCES:I. Disclose Required By Law: Our practice 1 use and disclose your PHI when we are requiredto do so by federal, state, or local law, including health oversight activities, court oradministrative orders or similar le(al proceedings.2. Public Health Risk: Our practice may disclose your PHI to public health authorities who areauthorized to collect information for such purposes as maintaining vital records, preventing orcontrolling disease, injury, or disability; or notifying a person regarding potential exposure to acommunicable disease.3. Serious Threats to Health of Safety: Our practice may disclose your PHI when necessary toreduce or prevent a serious threat to your health and safety or the health and safety of anotherindividual or the public.4. Deceased Patients: Our practice may release PHI to a medical examiner or coroner to identifya deceased individual or to identify-the cause of death. If necessary, we also may releaseinformation in order for funeral directors to perform their jobs.5. Organ Donor: Our practice may release PHI to a medical facility for tissue procurement oftransplantation, including organ donation banks, as necessary to facilitate organ or tissuedonation and transplantation if you are an organ donor.6. Work r's Compenaatlon: Our practice may release your PHI for workers' compensation andsimilar programs.Our practice may contact you or your authorized representatives (see authorization form attached) to