Gastroenterology Hepatology Nutrition

1901 NEWPORT BLVD., STE. 235, COSTA MESA, CA. 92627Ph 949 646-6224 Fax 949 646-6222

Patient Name: __________________________________ Sex: M F Address: ______________________________________ Date of Birth _________

City: ____________________________ State: ______ Zip: _______ Ph # ( ) ____________

Email ______________________________ ****************************************************************************Father’s Name: __________________________ DOB: _______Social Security # ___________Father’s Employer: _____________________ Work Phone: _____________ Cell#: __________ Work Address: _________________________ _________________ __________ Street City ZipDrivers License # ___________________ State ______ Exp. Dt. _________

*****************************************************************************Mother’s Name: _________________________ DOB: _______ Social Security# ____________Mother’s Employer: ____________________ Work Phone: ______________ Cell#: _________Work Address: __________________________ ________________ ___________ Street City ZipDrivers License # ___________________ State_______ Exp Dt. __________

******************************************************************************Medical Insurance: Primary ________________________ ID# ____________ Group # ____________Subscriber ___________________________________ Date of Birth ____________HMO _____ PPO ____

Secondary ______________________ ID# _____________ Group ____________Subscriber _____________________________________ Date of Birth ____________HMO _____ PPO ____

****************************************************************************** Emergency Contact (other than parent)

Name ____________________________ Ph# _______________________ Relationship _____________

Who may we thank for referring you to our office? __________________ Ph # _____________

__________________________________ _____________________________Today’s Date Patient or Guardian Signature

Anjuli Kumar, M.D. Mini Mehra, M.D. Barry Steinmetz, M.D. Robert Tran, M.D. Malinda Lin, M.D.

PEDIATRIC GASTROENTEROLOGY PATIENT HISTORY FORMPlease help us get to know you and your child better by providing us with the following information.

Pt name: _________________________________________ DOB: ____/____/_______

Mother/Guardian Occupation Does your child have any siblings?

Father/Guardian Occupation Who does the patient live with?

Primary Care Physician/Pediatrician Phone: Fax:

Other doctors involved in your care:

Review of Systems: Please help us understand your child’s health history by answering the following questions.Has your child ever been diagnosed with any of the following? If YES, please check any that apply and explain in the space provided.

SYSTEM YES NO SYSTEM YES NO SYSTEM YES NO SYSTEM YES NO

Birth History Heart Endocrine/ Metabolic SkinBirth Wt: High blood

pressureDiabetes Rash

Normal Low blood pressure

Thyroid disease

Lesions

Premature Irregular heartbeat

Brain/Neurological Dietary

Caesarean Chest pain Seizures Restricted dietVentilator Lungs Weakness Weight lossIntestinal/ GI issues Asthma Headaches Obesity

Diarrhea Pneumonia Migraines Food allergiesConstipation Chronic cough Blind/deaf PsychosocialRectal bleeding

Hoarseness Cerebral palsy

Depression

Heartburn Kidney/ Urinary Mental retardation

Anxiety

Trouble swallowing

Kidney disease

Blood/ Bleeding Alcoholism

Nausea Frequent urine infection

Hemophiliac Substance Abuse

Vomiting Pain with urination

Easy bruising Other

Abdominal pain

Bedwetting Sickle Cell

JaundiceLiver disease

Please continue on the next page

Page 1

PEDIATRIC GASTROENTEROLOGY PATIENT HISTORY FORM-page 2

Past Medical History: Please answer the following questions about your child’s past medical problems.

Please explain any YES answers in detailed description in the box provided

Have he/she ever had any surgery or been hospitalized? __No __Yes, Please explain

Have he/she had any problems with anesthesia? __No __Yes, please explain:

Surgeries: (Please also provide dates)

Hospitalizations other than surgery:

Is he/she currently taking any medications or vitamins?

Please list medications:1.2.3.4.

Drug Allergies:

Family History: Please indicate if you or your spouse, your parents, family members, and/or children ever had any significant medical conditions:

Age Medical problemsMotherFatherSiblings1.2.Grandparents:1.2.

Social History: Please answer the following about your child’s home environment

Grade in school: Hobbies: Extracurricular activities:

Tobacco use in the house?__No __Yes

Alcohol use?__No __Yes

Pets:

Current Pharmacy Used Name __________________ Location ____________________________________Compounding Pharmacy if needed Name ___________________ Location ______________________________

Preferred Lab (please ck) ___Quest ___ Labcorp

Please feel free to provide your GI specialist with any additional information that you think is important in allowing them to get to know you and your child better.

_____________________________________ _____________________________ ________________Person completing this form Relationship to patient Date

_____________________________________ ________________Reviewed by provider Date

PEDIACTRIC GASTROENTEROLOGY ASSOCIATES

OF SOUTHERN CALIFORNIA

Overview of our Financial Responsibilities

PGASC’s Responsibility- To post charges and payments accurately. To process claims and statements to the

responsible party based on the best information available to us. This includes direct insurance billing and patient

billing for remaining balances. To provide accurate financial counsel to parents who contact our billing office.

Parent/Patient Responsibility- To assure that PGASC is provided with the most current insurance information

known. To provide timely payment to PGASC for all balances known to be the responsibility of the parent/patient.

To be responsible for all copays, deductibles and coinsurance at the time of service.

General Payment Policies:

• Insurance Coverage

We ask that you bring your child’s insurance card with you each time you visit our office. When you check in at our front desk at

each visit, we will ask to see and verify your child’s insurance card for our records. Making a copy of your insurance card does not

confirm that PGASC providers are contracted with your insurance plan. It is your responsibility to know whether PGASC is a

provider for your insurance company. If you do not have your insurance card with you at your child’s visit, you may be asked to pay

at the time of service and/or sign a waiver of responsibility. Once the current information is furnished to us, and the insurance

company makes payment, PGASC will issue you a reimbursement payment.

Initial ______

• Changes in Insurance Coverage

If there is any change in insurance, it is your responsibility to bring it to our attention immediately. Delays in communicating these

changes may result in the balance being uncollectible from the insurance company and the responsibility for payment will fall upon

the parent/patient.

Initial _____

• HMO Insurance

PGASC is contracted with many HMO networks. It is your responsibility to have the approved referral/ authorization at the time

of your appointment.

Initial _____

• Cash Patients

Payment in full is required at the time of service. Any exceptions to this policy must be arranged with management prior to the date of

your visit.

Initial _____

• Collection Accounts

PGASC exhausts all efforts to research and resolve aged accounts prior to sending to an outside agency. In the event that an account is

sent to a collection agency, an additional 30% fee will incur in addition to 1.8% monthly interest. These are separate charges from

services rendered by our group. You will also be responsible for all attorney fees that incur.

Initial ______

• Missed Appointments

Our policy is to call and confirm all appointments the day before. In the event that you are unable to make your appointment, we

require a 24-hour cancellation notice. If you are running late, we always appreciate a phone call to the office Please note that if you

are significantly late, we will try our very best to still see you. There are times that we might need to reschedule your appointment so

that our providers can spend an adequate amount of time with your child and other patients.

Initial _____

Billing Inquiries

Thank you for taking the time to understand our financial policies. PGASC’s goal is to provide quality care! If

you have any questions regarding your plan benefits or limitations, please contact your insurance carrier

directly. If you have any questions or concerns about the financial aspects of your relationship with PGASC,

please feel free to contact our business department at (949) 698-8215.

Authorization/Consent Patient _______________________________ Date of Birth __________ Parent/Guardian ______________________________

Print Name Signature

Yes ___ No ___ I hereby authorize PGASC to provide medical treatment to the patient listed on this form.

Yes ___ No ___ I hereby authorize third parties to pay directly to PGASC any insurance benefits due for services

rendered on behalf of the named patient.

Yes ___ No ___ I authorize PGASC to furnish my insurance company any medical information necessary to process our

Insurance claims.

To Our Patients,

To ensure you and your child fully benefit from the medical care and treatment planned by your

Physician, we ask for your cooperation by following our policy for arriving on time to appointments and

keeping schedule appointments.

Here is a summary of our policy requirements:

1. Arriving on time for scheduled appointments

• Patients who arrive more than 15 minutes late may have their appointment cancelled and

rescheduled.

2. Cancelling Appointments

• It is important for you and your child’s medical care to keep all scheduled appointments

• We require a call to cancel more than 24 hours before a scheduled appointments, this

allows us to schedule another patient waiting for an appointment.

• Calling less than 24 hours before a scheduled appointment is considered a missed

appointment.

• Not arriving for an appointment is considered a missed appointment.

I have read and understand that when I make an appointment and do not call within 24 hours to

cancel, another patient could have that appointment and I will be charged $30.

Date:_____________________ Name of Patient (print):______________________________________

Signature:________________________________ Relationship to patient:_____________________

PEDIATRIC GASTROENTEROLOGY

ASSOCIATES OF SOUTHERN CALIFORNIA

Anjuli Kumar, M.D. Mini Mehra, M.D. Barry Steinmetz, M.D. Robert Tran, M.D.

COSTA MESA—1901 Newport Blvd, Suite 235 Costa Mesa, CA 92627 Tel: 949-646-6224 Fax: 949-646-6222

LONG BEACH –- 1760 Termino Ave, Suite 300 Long Beach, CA 90804 Tel: 562-933-3009 Fax: 562-933-8557

TORRANCE –- 3640 Lomita Blvd, Suite 102 Torrance, CA 90505 Tel: 310-378-1716 Fax: 562-933-6743

www.SoCalKidsGI.com

PEDIATRIC GASTROENTEROLOGY

ASSOCIATES OF SOUTHERN CALIFORNIA

1901 Newport Blvd. Suite 235 Costa Mesa, CA 92627

Tel 949)646-6224 Fax 949)646-6222

www.SoCalKidsGI.com

IMPORTANT NOTICE

Pediatric Gastroenterology Associates of Southern California makes every effort to refer you to

“in network” laboratories and imaging facilities that are members of most health plans.

However due to changes in the healthcare industry, some insurance carriers have chosen to

“contract” with specific laboratories and imaging facilities for their members.

If your insurance carrier chooses to contract with a specific facility, it is your responsibility to

notify us so that we can refer you to those contracted providers. With more than 100 plans for

which we are providers, it is not possible for us to know the details of each of these plans as we

are not always notified by your insurance carrier.

PLEASE BE AWARE THAT IT IS YOUR RESPONSIBILITY

TO KNOW THE DETAILS OF YOUR HEALTH PLAN

If you are in doubt as to whether a procedure, laboratory test, or imaging request is covered

and where it must be performed, please contact your insurance carrier.

Our office is not responsible for any out of pocket expenses resulting from the use of a non-

contracted facility or for tests/procedures not covered under your benefit plan.

Thank you for your understanding.

Signature: Date:___________________

Relationship to patient:_____________________________________________

Print Patient Name:________________________________________________

Gastroenterology Hepatology Nutrition