lighthouse pediatrics · lighthouse pediatrics may use your phi without written consent to...

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 #: ______________________

2


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

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):

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

5

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: ________________________

6

Early Death (less than 50)

QUESTIONS/CONCERNS:______________________________________________

7

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:


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.

8

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 _____________________

9


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

10


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

11


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______________

12


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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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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