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120215 Reg Form _Under 2 Yrs Old

120215 Reg Form _Under 2 Yrs Old

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Published by: Heart of the Valley, Pediatric Cardiology on Feb 23, 2012
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05/28/2012

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Patient Registration Form(Patients under 2 yrs old)
Rev 2/15/12
SECTION II – INSURANCE ACCOUNT INFORMATIONSECTION I – PERSONAL INFORMATION
Patient Name: Date:
Last Middle First
Social Security #: Date of Birth:
Male
 
FemaleAddress:
Street City State Zip
Home Phone #: Email: Cell#:Mother’s Name: Employer: Emp Ph #:
 
Mother’s Social Security #: Cell Phone #:Father’s Name: Employer: Emp Ph#:Father’s Social Security #: Cell Phone #:Emergency Contact: Relationship: Ph#:Primary Physician: City: Ph#:(If the physician who referred you is different from your primary physician, please tell us who referred you.)Referring Physician: City: Ph#:Preferred Pharmacy:Primary Insurance:Subscriber Name:Subscriber Birthday:Social Security #:Relation to patient:Insurance ID #:Group #:Secondary Insurance:Subscriber Name:Subscriber Birthday:Social Security #:Relation to patient:Insurance ID #:Group #:
 
 
SECTION III – MEDICAL HISTORY
Past Medical History
Reason for today’s visit:Birth weight: Full Term/ Gestational Age: Birth method:Hospital: Any pregnancy/ delivery complications? Normal feeding and growth?
Yes
No - explain:Would you describe their activity as energetic?
Yes
No - explain:Drug allergies?
No
Yes:Is patient currently taking medications?
No
Yes: Dosage: Frequ:
Surgical History
Any surgeries?
No
Yes - explain:Circumcision: What age? Complications?
No
Yes - explain:
Social History
Are parents:
Married
Divorced Is child:
Foster Care
AdoptedWho does the child live with?
 
SECTION IV – FAMILY HISTORY
Any history of heart disease, high cholesterol, high blood pressure, or heart attack?
Mother – explain:
Father – explain:
Maternal Grandparents– explain:
Paternal Grandparents – explain:Any other health issues (ie diabetes, cancer, etc)?
No
Yes - explain:# Brothers: Health issues?
No
Yes - explain:# Sisters: Health issues?
No
Yes - explain:
Has any family member…
Had a sudden, unexpected death before age 50 (including from sudden infant death syn-drome [SIDS], car accident, drowning, or others)? …………………………………………….
Yes
NoDied suddenly of “heart problems” before age 50? …………………………………………….
Yes
NoHad unexplained fainting or seizures? ………………………………………………………….
Yes
NoBeen identified with certain conditions such as:Hypertrophic cardiomyopathy (HCM) ……………………………………………………..
Yes
NoDilated cardiomyopathy (DCM) ……………………………………………………………
Yes
NoAortic rupture or Marfan syndrome …………………………………………………………
Yes
NoCoronary artery atherosclerotic disease …………………………………………………….
Yes
NoHeart attack, age 50 years or younger ………………………………………………............
Yes
NoArrhythmogenic right ventricular cardiomyopathy ……………………………………………..
Yes
NoCatecholaminergic polymorphic ventricular tachycardia ……………………………………….
Yes
No
Long QT syndrome,
Short QT syndrome,
Brugada syndromePacemaker or implanted cardiac defibrillator ……………………………………………………
Yes
NoPrimary pulmonary hypertension ………………………………………………………………..
Yes
NoCongential deafness (deaf at birth) ………………………………………………………………
Yes
No
 
 
ALL OF THE INFORMATION BELOW MUST BE READ, COMPLETED AND SIGNEDIN ORDER FOR THE DOCTOR TO SEE YOU
PAYMENT POLICY:
Heart of the Valley Pediatric Cardiology (HOTV) requires that a guarantee of full payment be made for all service prior to being seen by enrollment in an
EasyPay
® plan*. * See EasyPay information and enrollment sheet.Copayments and one half any deductible are due at the time of service.
Other Important Financial Policies:
1)
 
Patients with HMO's and PPO's with which we contract should only be ultimately responsible for co-payment and deductibles provided all information provided by the responsible party is accurate and any required pre-authorizations have been obtained prior to treatment. Patients with an HMO will be held
 
financially responsible for all charges incurred which are not pre-authorized.2)
 
Even though HOTV will do its best to pre-verify eligibility, it is still the responsibility of the responsible party to maintain andverify eligibility with insurance companies, regardless of whether one has public (MediCal etc) or private insurance.3)
 
There is a $35 charge for all returned checks.
 
 ___________ 
Initials
 4)
 
A $100.00 fee for ALL patients will be charged for missed appointments not cancelled within (24) twenty-four hoursprior to the scheduled appointment. PLEASE NOTE: WE DO CONDUCT COURTESY CALLS PRIOR TO YOURAPPOINTMENT; HOWEVER IT IS NOT OUR RESPONSIBILITY TO REMIND YOU. We will call your home and, if available, cell phone to remind you of the upcoming appointment. ___________ Initials
 5)
 
Holter Monitors given out to patients must be returned within (72) seventy-two hours of receipt. Holter Monitors given out ona Friday must be returned the following Tuesday. Otherwise a $25.00 fee will be added per day late. ___________ 
Initials
 6)
 
In the event that your account must be turned over to collections, a collection fee equal to 50% of the balance will be added toyour account. Balances due beyond the date specified for the payment option chosen will be turned over to collections.7)
 
Visit our website or ask us for a complete explanation of our Payment Policies.
UNDERSTANDING, ASSIGNMENT AND RELEASE:
I am the Responsible Party for this patient. I have read and understand the payment policy. I authorize the release of medical information by Heart of the Valley Pediatric Cardiology to my primary care doctor, my referring doctor, toconsultants if needed and as necessary to process claims, insurance applications and prescriptions.I authorize direct payment of medical benefits to Heart of the Valley Pediatric Cardiology through my insurance companyand by participation in one of the two Payment Guarantee plans or I will pay-in-full the estimated charges for each visit atthe time of visit. I understand this assignment will stay in effect as long as the patient remains in this practice.I understand that I must submit a current and valid insurance card in order to have the insurance company billed directly. Iunderstand that if I fail to submit a valid and current insurance card or if I fail to provide a valid secondary insurance card Iwill be billed at the non-contracted rate for services payable within 15 days of my billing date. I understand that anyinsurance disputes will be settled between the insurance company and me and any unpaid balance will be due and payablewithin 15 days of the billing date.Signature: _____________________________________ Date: ________________ 
 

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