Registration form

Patient 1

Basic info

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Sex
Hispanic or Latino
Race

Patient 2

Basic info

MM slash DD slash YYYY
Sex
Hispanic or Latino
Race

Patient 3

Basic info

MM slash DD slash YYYY
Sex
Hispanic or Latino
Race

Pediatrician

Primary care physician

How did you hear about us?

Primary office

Parent/Guardian 1

Primary address

General info

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Lives with patient?

Parent/Guardian 2

Primary address

General info

MM slash DD slash YYYY
Lives with patient?

Legal custody

Who has custody of the patient

If parents are divorced or separated (Only complete if applicable)

We believe that divorce, separation and custody agreements should not enter into a child’s medical treatment. The parent who is requesting the medical treatment is individually responsible for the payment of the medical bills. We are not a party to your divorce agreement; we will collect co-pays and deductibles from the *attending parent.*


“Joint Custody” means that each parent has equal access to the child’s medical record. Without a court order, we will not stop either parent from looking at their child’s chart or obtaining their child’s test results. In the circumstance of joint custody, we will not call the other parent for
consent prior to treatment or to inform the non present parent of the assessment and/or plan of care, if any. Again, we will discuss with the* accompanying parent*, information pertinent to the child’s history and/or present exam. It is then the responsibility of the parents to communicate with each other.
We reserve the right to charge an administrative fee for copying records should the requests become excessive.


Should issues between the parents become disruptive to our medical practice, we reserve the right to discharge a family from our care and responsibility.

Legal restrictions

Authorized individuals

Authorized 1

I understand that an authorized individual must present a valid photo ID at the visit.(Required)

Authorized 2

I understand that an authorized individual must present a valid photo ID at the visit.(Required)

Consent to payment and treatement

Primary insurance

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Secondary insurance

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Credit card authorization

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ASSIGNMENT OF BENEFITS I hereby assign and authorize payment directly to Pediatric Associates of Kingston, LLC (“Pediatric Associates”), and to any physician employed by or contracted with Pediatric Associates, all insurance benefits, sick benefits, injury benefits due because of liability of a third-party, or proceeds of all claims resulting from the liability of a third party, payable by any party, organization, et cetera, to or for the pediatric patient and the NEPA Breastfeeding Center patient, as applicable. If pediatric patient and/or NEPA Breastfeeding Center patient is eligible for Medicaid, I have requested Medicaid services and benefits. I further agree that this assignment will not be withdrawn or voided at any time until the pediatric patient’s and/or the Breastfeeding Center of NEPA patient’s account is paid in full.

I understand that I may be responsible for payment in full of any amount due that is not covered or paid for by my insurance policy, benefit plan, or other payor. I understand that in this case, I am obligated to pay Pediatric Associates in accordance with its regular rates and terms. If I fail to make payment when due and the account becomes delinquent or is turned over to a collection agency or an attorney for collection, I agree to pay all collection agency fees, and associated court costs and attorney’s fees. I also agree that any patient or guarantor over payments may be applied directly to any delinquent account for which I or my guarantor is legally responsible at the time of the collection of the over payment.

RELEASE OF INFORMATION AND STATEMENT OF ASSISTANCE



I authorize Pediatric Associates to furnish and release to my insurance carrier(s) or their representatives insuring the pediatric patient and/or the NEPA Breastfeeding Center patient any and all portions of the pediatric patient’s and the NEPA Breastfeeding Center patient’s medical records which may be necessary for completion of any claims for services, supplies, and equipment provided.



I consent for the Pediatric Associates and/or its attorneys to request, on my behalf, any information related to my health insurance policy (including, but not limited to, proof of insurance). This information may be given directly to Pediatric Associates and/or its attorneys.



I authorize Pediatric Associates to appeal on my behalf any denial for reimbursement, coverage, or payment for services or care provided to the pediatric patient and/or the NEPA Breastfeeding Center patient, as applicable. I agree to assist Pediatric Associates in collecting benefits that may be due or payable under my insurance policy for the services, supplies, and equipment provided.



I agree to provide Pediatric Associates and/or its attorneys with any additional information needed to process claims for payment. CONSENT FOR TREATMENT In this section, the term “patient” refers to the pediatric patient. The term “patients” refers to both the pediatric patient and the NEPA Breastfeeding Center patient, if applicable.



I hereby voluntarily authorize treatment of the patient or patients, as applicable, at Pediatric Associates.

I permit Pediatric Associates and its employees, physicians, fellows, residents, interns, and other qualified personnel involved in the patient’s or patients’ care to treat the patient or patients in ways they judge to be beneficial to the patient or patients.



I understand that I have the right to ask questions and to receive information about the patient’s or patients’ care and treatment, and the right to withdraw my consent for treatment or tests.



I understand that the results of any treatments, tests or care cannot be guaranteed. I also understand that I have the right to refuse any drugs, treatment, or procedures to the extent permitted by law for the patient or patients. I understand that medical, nursing, and other health care personnel in training may be observing and participating actively in the care of the patient or patients under the supervision of authorized personnel. I hereby give my consent to such observations and/or participation. I consent to the photographing, videotaping and/or video monitoring, including appropriate portions of the patient’s or patients’ body/ies, for medical and medical record documentation purposes, provided said photographs or videotapes are maintained and released in accordance with protected health information regulations.

Acknowledgments

I hereby certify that I have read the foregoing Consent  to Payment & Treatment, understand it, accept its terms, and was offered and/or received a copy of it.(Required)
I hereby acknowledge that I was offered and/or received a copy of and read Pediatric Associates’ Notice of Privacy Practices. (Click Link Below) We are asking you to acknowledge that you were offered or received a copy of our Notice of Privacy Practices. By signing below, you are not making any statement regarding the content of the Notice of Privacy Practices or about your agreement or disagreement with it or any portion of it. I understand that if I have questions or complaints relating to the Notice of Privacy Practices, I may contact the Practice Administrator at (570) 288-6543.(Required)
I hereby authorize PAK Pediatrics to charge the credit card listed on file for any unpaid co-payments, coinsurance, deductibles or balances aged 60+ days that are less than $100. For any balance exceeding $100, I understand that PAK Pediatrics will contact me to discuss payment arrangements before processing the charge. By clicking below, I acknowledge and agree to these terms and understand it is my responsibility to ensure the credit card information on file remains up to date.(Required)

Portal user

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I hereby authorize PAK to enroll the following email address for PAK Patient Portal to access CHADIS questionnaires, Immunizations, child’s medical records & portal messages:(Required)
I hereby acknowledge that I was offered and/or received a copy of and read Pediatric Associates’ Intent to Immunize.(Required)
I hereby acknowledge that I was offered and/or received a copy of and read Pediatric Associates' Financial Policy.(Required)
I hereby certify that I am authorized as the pediatric patient’s parent, guardian, or other legal representative to execute this Consent and, if applicable, that I am the NEPA Breastfeeding Center patient.(Required)