Download New patient paperwork - TLC Pediatrics

TLC Pediatrics
4520 Linden Creek Parkway, Suite F, Flint, MI 48507
Phone # 810-244-1168 Fax # 810-244-1172
PATIENT INFORMATION SHEET
(This is an official form and part of your child’s permanent medical record, please do not draw or doodle on either side of this form)
Child’s Name: _____________________________ Date of Birth: __________________ Male/Female
Child’s SSN: ___________________ Race__________________ Please circle one: Hispanic/Latino/Other
Father’s Name: __________________________ Date of Birth:_______________ Cell#______________
Address________________________________City____________________Zip Code_______________
Mother’s Name: _________________________Date of Birth: _______________ Cell#______________
Address________________________________City____________________Zip Code_______________
Emergency Contact Person (other than parents)
Name: _____________________________Phone#_______________Relationship:_________________
Other Contact person whom have authorization to obtain medical information and/or seek medical
care for this child:
Name: _______________________Phone#_____________________Relationship__________________
Name: _______________________Phone#_____________________Relationship__________________
Previous Physician Name:________________________________Phone#_________________________
Address:__________________________City:_________________State:______Zip Code_____________
Insurance Information
Name of Insurance Company______________________________Subscriber_____________________
Subscriber DOB_____________ Social Security #________________Relationship__________________
Policy or ID #________________________________Group #__________________________________
Secondary Insurance Company ____________________________Subscriber_____________________
Subscriber DOB_____________ Social Security #________________Relationship__________________
Policy or ID #________________________________Group #__________________________________
Patient Name(s) & Date of Birth:
______________________________________________________________________________
______________________________________________________________________________
Rights and Responsibilities
As a service to our patients with medical insurance, we will bill your insurance company as long as you
provide us with the correct insurance information on the date of service. Please remember that your
medical insurance is a contract between you and your employer/insurance company and you are
responsible for the non-covered charges or clauses in the contract/policy.
I understand and agree that (regardless of my insurance status) I am responsible for knowing my policy
coverage and I am responsible for the balance of this account for any professional service rendered for
my child/ren. I am also aware that if this account is not paid in full and it is turned over to a collection
agency, all of the children attached to this account will be discharged from this office, this includes but is
not limited to biological, half and step siblings or a child that the parent/s is a guardian of. Each parent’s
information will be sent to the collection agency regardless of legal responsibility status.
I will notify TLC Pediatrics of any changes in my child’s health insurance status or the above information
when applicable.
This a direct assignment of my rights and benefits under this policy for payment made directly to:
Sarah Sanchez MD or Cynthia Horning MD. I also authorize the release of information pertinent to my
child’s case/claim to any insurance company involved.
I understand that upon the request of Release of Records for my child/ren’s records to another facility
the account balance must be paid in full prior to TLC Pediatrics processing this request and there will be
a copy service charge per record that must be paid prior to the records being released from this office.
I certify this information is true and correct to the best of my knowledge.
_______________________________________________________/_____________________________
Parent/Guardian Signature
_______________________________________________________
Parent/Guardian Printed Name
Date
TLC Pediatrics
NOTICE OF PRIVACY PRACTICES AND ACKNOWLEDGEMENT
I, the undersigned, acknowledge receipt of the Notice of Privacy Practices.
_______________________________________________________________/_____________________
(Signature patient or personal representative)
(DATE)
If Personal Representative’s signature appears above, please describe Personal Representative’s
relationship to the patient.
Mother
*To be filed and retained for a minimum of six (6) years.
Father
Guardian
Medical History Form
Date of Visit: ________________
Patient Name: ______________________________
Date of Birth: ________________
Health History:
Current Problem: _______________________________________________________
Past Problems: _________________________________________________________
Hospitalizations (approx date): ____________________________________________
_____________________________________________________________________
Surgeries (approx date): _________________________________________________
_____________________________________________________________________
Medications: __________________________________________________________
_____________________________________________________________________
Allergies: _____________________________________________________________
_____________________________________________________________________
Social History:
Who lives at home: _____________________________________________________
_____________________________________________________________________
Smoke detector: Y N
Carbon Monoxide Detectors: Y N
Pool/pond/lake near home: Y N
Firearms in home: Y N
Second hand smoke: Y N
Daycare: Y N
Pets: ________________________
Water: City Well
Medical Health Form
Date of Visit: ________________
Patient Name: __________________________
Date of Birth: _______________
Family History:
(Please circle those that apply. Indicate relationship to patient.)
Hypertension (high blood pressure)
Breast cancer
Myocardial infarction (heart attack)
Prostate cancer
Cerebrovascular accident (stroke)
Colon cancer
High cholesterol
Lymphoma
Heart disease
Lung cancer
Diabetes
Brain cancer
Hypothyroid (low thyroid)
Rheumatoid arthritis
Hyperthyroid (high thyroid)
Lupus
Hashimoto’s thyroiditis
Scleroderma
Grave’s disease
Asthma
Kidney Stones
COPD/emphysema
Polycystic kidneys
Seizures
Blood clots
Migraine
Factor V Leiden
Bipolar
Hemophilia
ADHD
MTHFR
Depression
Other: __________________________________________________________________
________________________________________________________________________
________________________________________________________________________