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Pediatric New Patient Form

Pediatric New Patient Form

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Published by Mr. Alma Myers, LAc
New patient forms for pediatric patients. Includes personal information, insurance and financing, intake and medical history, and other appropriate forms.
New patient forms for pediatric patients. Includes personal information, insurance and financing, intake and medical history, and other appropriate forms.

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Published by: Mr. Alma Myers, LAc on Feb 13, 2012
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New Patient (Pediatric)the Los Angeles Mobile Acupuncture groupPage 1
First Name:________________ Middle Initial_____ Last Name:________________________________ Address:__________________________________ City:______________________________________ State:_________________ Zip:________________ E-mail:_________________@_________________ Twitter:@__________________________________ Facebook.com/_____________________________ Google+__________________________________ Sex: M F Age:_______________ Birth Date:________________________________ Married Widowed Single MinorSeparated Divorced Partner for___years
:_______________________________ Employer/School:__________________________ Address:__________________________ __________________________ State:__________ Zip:_______________ Phone: ( ) _________ -_________ # of hours per week:_________________ 
:__________________________________ Date of Birth:__________ SSN:_____-_____-_____ Employer:_________________________________ Whom may we thank for referring you?_________  _________________________________________ 
Home: (_______)__________-________________ Cell: (_______)__________-________________ Work: (_______)__________-________________ Best time and place to reach you:______________  _________________________________________ 
Name:____________________________________ Relationship:__________________________ Cell #: (_____) ______ - ________________ 
Who is responsible for this account?_______________  ____________________________________________ Relationship to Patient:__________________________ Date of Birth:__________ SSN:_____-_____-_______ Insurance Co:_________________________________ Group #:_____________________________________ Phone #:(_______)_________ - _________________ Is patient covered by any additional insurance?Y NSubscriber’s Name:____________________________ Date of Birth:__________ SSN:_____-_____-_______ Relationship to patient:__________________________ Secondary Insurance Co:________________________ Group #:_____________________________________ Phone #:(______)________ - ____________________ 
Assignment and Release
I certify that I, and/or my dependant(s), have insurancecoverage with:________________________________ and assign directly to the Los Angeles MobileAcupuncture group, assigned provider or agents allinsurance benefits, if any, otherwise payable to me forservices rendered. I understand that I am financiallyresponsible for all charges whether or not paid by myinsurance submissions.Los Angeles Mobile Acupuncture and its providers mayuse my health care information and may disclose suchinformation to the above named insurancecompany(ies) and their agents for the purpose ofobtaining payment for services and determininginsurance benefits or the benefits payable for relatedservices. This consent will end upon written notice or 7years after last visit.
Patient Signature
(Or Patient Representative) Date
PO Box 352116, Los Angeles, CA 90035-1515 • P: (866) 629-8089 F: (866) 629-8089 • www.lamobileacu.com • version 1-18-2012
Intake & Medical Historythe Los Angeles Mobile Acupuncture groupPage 2
Home: (_____) ______ - ________________ Work: (_____) ______ - _________________ 
(Indicate relationship if signing for patient)
PO Box 352116, Los Angeles, CA 90035-1515 • P: (866) 629-8089 F: (866) 629-8089 • www.lamobileacu.com • version 1-18-2012
New Patient (Pediatric)the Los Angeles Mobile Acupuncture groupPage 3
Patient Printed Name:________________________________________________________________________ 
We would like to take a moment to welcome you to our office and assure you that youwill receive the very best of care available for your condition. In order to familiarize youwith the financial policy of this office we would like to explain how your medical bills willbe handled.
Explanation of Insurance Coverage:
Many insurance policies do cover acupuncture care but this office makes norepresentation that yours does. Insurance policies may vary greatly in terms of deductible and percentage of coverage for acupuncture care. Because of the variancefrom one insurance policy to another, we require that you, the patient, be personallyresponsible for the payment of your deductibles, as well as any unpaid balances in thisoffice. We will do our best to verify your insurance coverage, and will bill your insurancein a timely manner.
Payment Arrangements
We require that you pay $20 towards today’s charges and $20 on each visit. Your fullportion of the bill is expected to be when payment is received from your insurancecarrier. Any unpaid balances will be considered past due 30 days following insurancereimbursement Past due balances may have an interest charge of 1.5 % applied permonth.
Assignment of Benefits
Attached is an “Assignment of Benefits” form which we would like you to sign. This formdirects your insurance company to send payments directly to this office. If yourinsurance carrier sends payment to you for services incurred in this office, you agree tosend or bring those payments to this office upon receipt. If you pay for your visits in fullthe assignment need not be signed and the payments will be sent directly to you fromthe insurance.
Release of Information
If your insurance company requires medical reports or records to document yourtreatment or progress, your signature below authorizes this office to release the medicalinformation necessary to process your claim.
Voluntary Termination of Care
If you suspend or terminate your care at any time, your portion of all charges forprofessional services is immediately due and payable to this office. All services renderedby this office are charged directly to you, and you, ultimately will be personallyresponsible for payment regardless of your insurance coverage.
PO Box 352116, Los Angeles, CA 90035-1515 • P: (866) 629-8089 F: (866) 629-8089 • www.lamobileacu.com • version 1-18-2012

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