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Lighthouse Pediatrics
Patient Information Office Use Only
Today’s Date: ___________________________Referred by: ____________________________
PATIENT INFORMATION:______________________________________________
(Please Print)
Full Legal name: ____________________________________ Preferred Name: _____________
Race: Caucasian (white), American Indian, African American (black), Hispanic, Biracial, Asian, Other:
________________________________
Date of Birth: ________________ SS# ____________________ Sex: Male / Female
Home Address: ________________________________City: _________________________State:______
Zip Code: __________ County: ____________________
(If different)
Mailing Address: ________________________________City: ________________________State:
______ Zip Code: __________ County: ____________________
Primary Phone Number: _________________________
Cell Phone Number: ____________________________
Preferred Language: ____________________ E-mail: _______________________________________
Name of School/Daycare: _________________________________________________________
GUARANTOR/INSURANCE INFORMATION:______ ________________________
Name: __________________________________ Patient Relation to Guarantor: ____________
DOB: ___________ SS# ____________________ Primary Phone: _______________________
Address: ________________________________City: ______________State: ______
Zip Code: ______________
InsuranceCompanyName:_____________________________________________
Identification Number: _________________________ Group Number: ___________________
Effective Date: ______________________
Phone Number: _______________________
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PARENT / GUARDIAN INFORMATION:___________________________________
Father: _____________________________DOB: ____________SS# ______________________
Employer: ________________________________
Work # ____________________________ Cell # ______________________________
Address: ________________________________City: ________________State: ______
Zip Code: __________ County: _________________
_________________________________________________________________________________
Mother: ____________________________ DOB: ___________ SS# _________________
Employer: ________________________________
Work # ___________________________ Cell # ______________________________
Address: ________________________________City: ________________State: ______
Zip Code: __________ County: _________________
Emergency Contact:__________________________________________________
Name: ____________________________________________ Relationship_________________
(Other than PARENT)
Address: ________________________________City: _____________________ State: _______
Zip Code: _____________
Phone #: ______________________ Cell #: ______________________
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Lighthouse Pediatrics
PATIENT HISTORY QUESTIONAIRE
MOTHER’S PREGNANCY:______________________________________________
Age: _______ Any Problems? ______________________________________________________
Medications? __________________________________________________________________
During Pregnancy was there any:
Smoking? Alcohol? Illegal Drugs? Infections?
Was baby:
Early? On Time? Late? Type of delivery? ________________
_BIRTH:____________________________________________________________
Weight: _____________ lbs _____________oz Length: _____________inches
APGAR Scores: __________________
Problems with baby:
Breathing? Jaundice? Bili Lights? Others: ____________________________
FEEDING AND NUTRITION:_____________________________________________
Colic or feeding problems within the first three months?
_____________________________________________________________________________
Breast Fed? Number Of months: _________________
Supplemented?
Formula? Current Brand: ______________________________________________
Age baby food started: ______________________________
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ALLERGIES:_________________________________________________________
Medicine: __________________ Animals: ____________________ Food: __________________
IS CHILD ON MEDICATIONS? ______________________________________________________
IMMUNIZATIONS: Up to Date?
PAST MEDICAL HISTORY:______________________________________________
Chronic medical problems?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Hospitalizations?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Surgeries/Serious Injuries? (Where-When-Why)?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
DOES YOUR CHILD HAVE OR HAD ANY OF THE FOLLOWING?
Asthma/Wheezing Fractures Freq. Ear Infections Urinary Infections
Seizures Chicken PoxAllergies
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Yes No
Anemia Eczema Bleeding Disorder Blood Transfusion
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PROBLEMS OR CONCERNS WITH……
Hearing Vision Speech Development Other
DEVELOPMENT AND BEHAIVOR:
At what age did your child:
Sit alone ____________ Walk____________ Used Sentences____________
Toilet Trained____________ Bicycled ____________
Learning Problems?
Behavioral Problems?
Bedwetting?
Sleep Problems? Y/N Nail Biting? Y/N FAMILY PROFILE:____________________________________________________
PARENTS: Married? Separated? Divorced Smokers
Father’s age: _______ Highest School Grade? _______________________
Health? _____________________________________________________
Mother’s age: _______ Highest School Grade? ______________________
Health? _____________________________________________________
PATIENT’S siblings (name and age):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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FAMILY MEDICAL HISTORY____________________________________________
Check the box to any medical condition below that has affected any of your immediate family members
(parents, brothers, sisters, and grandparents) state your relationship in the relationship box. F- Father,_
M- Mother, B- Brother, S- Sister, MF- Mother’s Father, MM- Mother’s Mother, FM- Father’s Mother, FF-
Father’s Father, MS- Mother’s Sister, MB- Mother’s Brother, FS- Father’s Sister, FB- Father’s Brother.
Asthma Allergies Migraines Anemia Stroke
High Blood Pressure Heart Disease
Diabetes
Arthritis Drug/Alcohol Problem
Cholesterol Problems
SIDS AIDS
Cancer (Type) ____________________
Early deafness
Tuberculosis Mental Retardation
Cystic Fibrosis Birth defects
Epilepsy/Seizures
CURRENT PHARMACY: _______________________________________________
Preferred: _____________________________________________________________________
(Name & Location)
Phone Number: ________________________
Alternate Pharmacy: _____________________________________________________________
(Name & Location)
Phone Number: ________________________
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Early Death (less than 50)
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QUESTIONS/CONCERNS:______________________________________________
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Lighthouse Pediatrics 1201 Arapaho Ave
St Augustine, FL 32084 904-342-7648
Fax 904-342-8567
Vincent Luz M.D AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
I do hereby give my consent to: _______________________________________
_______________________________________
_______________________________________
to disclose and give copies of information to:
Lighthouse Pediatrics
1201 Arapaho Ave St Augustine, FL. 32084
Including the diagnosis and records of any treatment or examination rendered to my child:
_______________________________________ _______________________________
Patient Name (print) Date of Birth
Specifically, the following reports will be included:
Progress Notes X-ray reports Laboratory/ Pathology Reports
Consultation Reports Immunization Record Hospital Records
Other (specify) ___________________
______ (Initials) I DO (or) DO NOT consent to release of information relating to psychiatric or psychological testing or treatment, biofeedback training, alcohol and/or drug abuse
diagnoses, prognosis and treatment and/or HIV (AIDS) testing and/or results or such disclosure shall be
limited to the following specific types of information:
______________________________________________________________________________
Purpose of disclosure: Medical Care Other________________________________
This authorization shall be valid for 365 days from the date of signature. The patient can revoke the authorization in writing at any time prior to
the expiration date. The patient agrees that a photocopy of this authorization may be considered valid. I understand that when this
information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be
protected. I hereby release and hold harmless the above named facility and its parent company from all liability and damage resulting from the
lawful release of my Protected Health Information.
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EMERGENCY CARE/CONSENT FOR TREATMENT
Patients Name _________________________________Date of Birth________________
I hereby give permission to Lighthouse Pediatrics to direct any emergency medical treatment to my children during my absence.
It is understood that they will make every effort to contact me in case of medical emergency. It is further understood that if they are unable to contact me, that I give them this permission with my full consent. If hospitalization is necessary, I direct Lighthouse Pediatrics to arrange admission. I will be financially responsible for all hospital expenses.
For non-urgent care (well care, immunizations, minor illnesses, etc) it is necessary for you to list the individuals to whom you have given permission to bring the child in for care.Please list them below:
Name Relationship to Child (aunt, neighbor, etc)
_________________________________________ _____________________________________
_________________________________________ _____________________________________
_________________________________________ _____________________________________
_________________________________________ _____________________________________
__________________________________________ _____________________________________
Signed: __________________________________________ Date: ____________________
Witness: _________________________________________ Date _____________________
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Lighthouse Pediatrics
Medical Photography Release/Approval:
This practice is strongly dedicated to the use of the most advanced technologies available giving
and documenting your medical care. To this end, we have invested in electronic medical records. This
means that all items traditionally in a paper format will be obtained, stored and cataloged digitally. This
record will also include the digital photo of your child(ren) for identification by our staff. Any lesions,
procedures, or other items which may be documented visually, will also be stored and reproduced in
this manner. If you have no objection to the use of these photos we would greatly appreciate your
signature below.
I hereby authorize Lighthouse Pediatrics and it’s Representatives to obtain and reproduce
photographs of my child(ren)’s likeness(es) for purposes of medical records. I also approve of the use
and reproduction of clinical photos for referral, coding, charting, and education purposes.
_________________________________________ _____________________________
Signature of Parent or Legal Guardian Date
_________________________________________ _____________________________
Print Name of Parent or Legal Guardian Legal relation to child(ren)
List Name(s) of child(ren) covered in release
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________ Vincent Luz, MD
1201 Arapaho Ave
St Augustine FL 32084
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Lighthouse Pediatrics
PATIENT’S HIPAA ACKNOWLEDGEMENT
CHART # ______________ (for office use only)
PATIENT NAME: ___________________________________ DOB: ___________________
I HAVE READ THE “NOTICE OF PRIVACY PRACTICES” FOR LIGHTHOUSE PEDIATRICS.
___________________________________________________ ________________________
SIGNATURE DATE
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Lighthouse Pediatrics
Billing Policy
We are committed to providing you with the best possible care and we are ready to discuss our
professional fees with you at any time. Your understanding of our FINANCIAL POLICY is important to our
professional relationship. Please ask if you have any questions about our fees, our financial policy or
what your responsibility is.
FULL PAYMENT IS DUE AT THE TIME OF SERVICE
WE ACCEPT CASH, CHECK, VISA, MASTERCARD, AND DISCOVER
MINORS WHO ARE SEEN IN OUR OFFICE
An adult must accompany all minors and full payment is due at the time of service. If your child is old
enough to come to our office on his/her own they also will be required to pay at the time of service.
REGARDING BILLING
It is the policy of this office not to bill or extend credit. You are required to pay at the time of service.
We cannot hold checks. If you have an emergency or a problem paying please call our billing department
and they will discuss arrangements with you.
REGARDING INSURANCE
If we accept your insurance, you are responsible for any deductibles, coinsurance or co-pays at the time
of service. Insurance policies with required co-pays must be paid at the time of service or we may charge
YOU for the full amount of the visit. If your insurance carrier changes, it is your responsibility to notify us
when checking in. If you fail to do so, you may then become responsible for the full amount of the visit.
INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY. WE WILL NOT BECOME
INVOLVED IN DISPUTES BETWEEN YOU AND YOUR INSURANCE COMPANY. YOU ARE RESPONSIBLE FOR
THE TIMELY PAYMENT OF YOUR ACCOUNT.
The guardian who brings the child in is responsible for payment. Divorce settlement/financial
responsibility for the child issues are to be worked out between the parents.
I understand and agree that, regardless of my insurance status, I am responsible for the balance on my
account for any professional services rendered not covered by insurance. I have read all the information
above and understand it to the best of my knowledge. I will notify you of any and all future changes.
Signature of Parent/Guardian__________________________________ Date______________
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Lighthouse Pediatrics
Privacy Policy Notification
Lighthouse Pediatrics is committed to protecting the privacy of our patients. In accordance with
the Health Insurance Portability and Accountability Act of 1996 (HIPPA), Lighthouse Pediatrics has
created a Privacy Policy. The purpose of this notification is to familiarize yourself with the existence of
our policy as well as give you an overview of its contents. The full written policy is available to you on
request.
HIGHLIGHTS
Your Rights: You have a right to inspect and copy your protected health information. You have a
right to request a restriction of your protected health information. You have the right to have your
physician amend your health information. You have a right to receive an accounting of disclosures of
your protected health information.
Lighthouse Pediatrics will use your private information in a variety of ways to facilitate your
care. Some of these uses require your written consent and some do not. Private information (termed
Protected Health Information or PHI in HIPPA), includes anything which individually might identify you
(Name, SSN, diagnoses, etc)
Lighthouse Pediatrics may use your PHI without written consent to communicate with
emergency rooms, hospitals, specialists, lab and x-ray facilities, and other facilities involved in the
current treatment of the patient. In addition, Lighthouse Pediatrics will routinely use PHI in the
submission of billing to insurance companies. Also, any release required by law (mandatory notification
of contagious disease to the health department, issues involving abuse or neglect, adverse drug and
treatment reports to the FDA, issues involving criminal activity to law enforcement, or other releases
required by law) may take place.
Lighthouse Pediatrics requires your written consent to release PHI to parties other than those
listed above. This includes release to relatives other than immediate caregivers, to attorneys, to
employers, to life insurance or disability insurance carriers, to research projects, or any others not listed
previously.
Lighthouse Pediatrics does have business relationships with some companies who might
periodically have access to your PHI. These include our attorneys, practice management consultants,
computer system consultants and others. The purpose of these situations is for these entities to advise
us, internally, on our practice operations. Lighthouse Pediatrics maintains a contractual agreement with
these entities which restricts their use of private information to their business relationship with us.
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Lighthouse Pediatrics
Privacy Policy Notification Cont.
Lighthouse Pediatrics does increasingly use computer systems to transmit private information.
This is largely to transmit claim and referral information with insurers and to exchange private
information with other health care facilities. HIPPA mandates the secure electronic transmission of
private information and we are in compliance with those requirements.
Lighthouse Pediatrics does use PHI during the day to day operations of the office. While certain
uses of PHI (such as calling you by name in the waiting room) are acceptable, others (such as a person
overhearing a telephone call regarding your case) are not. From afterhours security systems, to keeping
charts out of patient areas, to minimizing the volume of our conversations, to shutting exam room doors
and others, we are committed to preventing inadvertent disclosures.
Your feedback about how we are doing in this or any other area is strongly encouraged.
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Todays Date: Referred by: City: Patient Relation to Guarantor: PATIENTS siblings name and age 1: PATIENTS siblings name and age 2: PATIENTS siblings name and age 3: Phone Number_3: AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS 1: AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS 2: AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS 3: Print Name of Parent or Legal Guardian: List Names of children covered in release 1: List Names of children covered in release 2: List Names of children covered in release 3: List Names of children covered in release 4: List Names of children covered in release 5: Date_3: Legal relation to children: CHART: PATIENT NAME: DOB_4: DATE: Date_4: Signature2_es_:signer:signature: Signature3_es_:signer:signature: Signature4_es_:signer:signature: Emergency Contact: Name: Emergency Contact: Relationship: Emergency Contact: Address: Emergency Contact: City: Emergency Contact: State: Emergency Contact: Zip Code: Emergency Contact: Phone: Emergency Contact: Cell Phone: Father: DOB: Father: SS: Father: Employer: Father: Work: Father: Cell: Father: Address: Father: City: Father: State: Father: Zip Code: Father: Country: Mother: Name: Mother: DOB: Mother: SS: Mother: Employer: Mother: Work #: Mother: Cell #: Mother: Address: Mother: City: Mother: State: Mother: Zip Code: Mother: County: Father: Name: Gurantor/Insurance: Name: Gurantor/Insurance: DOB: Gurantor/Insurance: SS: Gurantor/Insurance: Primary Phone: Gurantor/Insurance: Address: Gurantor/Insurance: City: Gurantor/Insurance: State: Gurantor/Insurance: Zip Code: Guarantor/Insurance: Group Number: Guarantor/Insurance: Identification Number: Guarantor/Insurance: Effective Date: Guarantor/Insurance: Phone Number: Guarantor/Insurance: InsuranceCompanyName: Patient info: Full Legal name: Patient info: Preferred Name: Patient info: Race (Other): Patient info: Date of Birth: Patient info: SS: Patient info: Sex: OffPatient info: Home Address: Patient info: State: Patient info: Zip Code: Patient info: County: Patient info: Mailing Address: Patient info: Mailing City: Patient info: Mailing State: Patient info: Mailing Zip Code: Patient info: Mailing County: Patient info: Primary Phone Number: Patient info: Cell Phone Number: Patient info: Preferred Language: Patient info: Email: Patient info: Name of SchoolDaycare: Mother Pregnancy: Age: Mother Pregnancy: Any Problems: Mother Pregnancy: Medications: Mother Pregnancy: Smoking?: OffMother Pregnancy: Alcohol: OffMother Pregnancy: Illegal Drugs: OffMother Pregnancy: Infections?: OffMother Pregnancy: Was Baby?: On-TimeMother Pregnancy: Type of delivery: Birth: Weight: Birth: lbs: Birth: Length: Birth: APGAR Scores: Birth: Problems with baby: Breathing?: OffBirth: Problems with baby: Jaundice?: OffBirth: Problems with baby: Bili Lights?: OffBirth: Problems with baby: Others: Feeding & Nutrition: Colic or feeding problems within the first three months: Feeding & Nutrition: Breast Feed? Number Of months: Feeding & Nutrition: Breast Fed?: OffFeeding & Nutrition: Supplemented?: OffFeeding & Nutrition: Formula?: OffFeeding & Nutrition: Formula? Current Brand: Feeding & Nutrition: Age baby food started: Allergies: Food?: Allergies: Animals?: Allergies: Medicine?: Allergies: IS CHILD ON MEDICATIONS: Past Medical History: Chronic medical problems 1: Past Medical History: Chronic medical problems 2: Past Medical History: Chronic medical problems 3: Immunizations Up to date?: YesPast Medical History: Hospitalizations 1: Past Medical History: Hospitalizations 2: Past Medical History: Hospitalizations 3: Past Medical History: SurgeriesSerious Injuries WhereWhenWhy 1: Past Medical History: SurgeriesSerious Injuries WhereWhenWhy 2: Past Medical History: SurgeriesSerious Injuries WhereWhenWhy 3: Does child have? Asthma/Wheezing?: OffDoes child have? Fractures: OffDoes child have? Freq Ear Infections: OffDoes child have? Urinary Infections: OffDoes child have? Allergies: OffDoes child have? Seizures: OffDoes child have? Chicken Pox: OffDoes child have? Anemia: OffDoes child have? Eczema: OffDoes child have? Bleeding Disorder: OffDoes child have? Blood Transfusion: OffProblems/Concerns with: Hearing?: OffProblems/Concerns with: Vision?: OffProblems/Concerns with: Speech?: OffProblems/Concerns with: Development?: OffProblems/Concerns with: Other?: OffDevelopment/Behavior: Sit alone?: Development/Behavior: Walk: Development/Behavior: Used Sentences: Development/Behavior: Toilet Trained: Development/Behavior: Bicycled: Development/Behavior: Bedwetting Problems?: Development/Behavior: Learning Problems?: Development/Behavior: Behavioral Problems?: Family Profile: Parent are?: YesFamily Profile: Fathers age?: Family Profile: Father's Health?: Family Profile: Father's Highest School Grade: Family Profile: Mothers age?: Family Profile: Mother's Highest School Grade: Family Profile: Mother's Health: Family Medical History: Asthma?: OffFamily Medical History: Allergies?: OffFamily Medical History: Migraines?: OffFamily Medical History: Anemia?: OffFamily Medical History: Stroke?: OffFamily Medical History: High Blood Pressure?: OffFamily Medical History: Heart Disease?: OffFamily Medical History: Cholesterol Problems?: OffFamily Medical History: Diabetes?: OffFamily Medical History: Arthritis?: OffFamily Medical History: Drug/Alcohol Problem?: OffFamily Medical History: SIDS?: OffFamily Medical History: Cancer?: OffFamily Medical History: Cancer Type?: Family Medical History: AIDS?: OffFamily Medical History: Early Deafness?: OffFamily Medical History: Tuberculosis?: OffFamily Medical History: Mental Retardation?: OffFamily Medical History: Epilepsy/Seizures?: OffFamily Medical History: Cystic Fibrosis?: OffFamily Medical History: Birth defects?: OffFamily Medical History: Early Death (less than 50): OffCurrent Pharmacy: Preferred?: Current Pharmacy: Phone Number: Current Pharmacy: Alternate Pharmacy?: Questions / Concerns: Authorization Forms: Patient Name (Printed): Authorization Forms: Child Date of Birth: Authorization Section: Included Reports - Progress Notes: OffAuthorization Section: Included Reports - X-Rays: OffAuthorization Section: Included Reports - Laboratory/Pathology Reports: OffAuthorization Section: Included Reports - Consultation Reports: OffAuthorization Section: Included Reports - Immunization Record: OffAuthorization Section: Included Reports - Hospital Records: OffAuthorization Section: Included Reports - Other (specify): OffAuthorization Section: Included Reports - Other (Specify): Authorization of Reports: YesAuthorization Section: Included Reports Initials: Authorization Forms: Consent Speficic Types of Info: Purpose of Disclosure?: YesAuthorization forms: Consent - Purpose of Disclosure - Other: Emergency Contact: Patients Name: Emergency Contact: Patient's Date of Birth: Emergency Consent Signature: Emergency Consent Signature Date: Emergency Consent Witness: Emergency Consent Witness Date: Emergency Contact: Name 5: Emergency Contact: Name 4: Emergency Contact: Name 2: Emergency Contact: Name 3: Emergency Contact: Name 1: Emergency Contact: Relationship to Child (1)?: Emergency Contact: Relationship to Child (2)?: Emergency Contact: Relationship to Child (3)?: Emergency Contact: Relationship to Child (4)?: Emergency Contact: Relationship to Child (5)?:
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