PEDIATRIC ASSOCIATES OF MADISON 21 Hughes Rd., Suite 2 ● Madison, Alabama 35758 ● 256-772-2037 ● Fax 256-772-9523

www.pedsofmadison.com

Robbie F. Dudley, M.D. Charlotte M. Meadows, M.D. Cynthia Dill, M.D. Jessica Magnusson, M.D Elizabeth M. Bryant, M.D. Veronica Collier, M.D.

Date: _____________ PATIENT REGISTRATION Chart #________________ PLEASE PRINT – FILL OUT ALL AREAS

PATIENT INFORMATION

CHILD’S NAME BIRTHDATE SSN SEX CELL PHONE# (14 YRS & OLDER)

1._____________________________________________________________________________________________________________________________________

Race: □ Asian □ African American □ White Other: _________________ Ethnicity: □ Hispanic □ Non-Hispanic

2._____________________________________________________________________________________________________________________________________

Race: □ Asian □ African American □ White Other: _________________ Ethnicity: □ Hispanic □ Non-Hispanic

3._____________________________________________________________________________________________________________________________________

Race: □ Asian □ African American □ White Other: _________________ Ethnicity: □ Hispanic □ Non-Hispanic

4._____________________________________________________________________________________________________________________________________

Race: □ Asian □ African American □ White Other:_________________ Ethnicity: □ Hispanic □ Non-Hispanic

PATIENT ADDRESS

_______________________________________________________________________________________________________________________________________

STREET CITY, STATE ZIP CODE

*PRIMARY CONTACT AND APPOINTMENT REMINDER PHONE # __________________________________________________________

PARENT INFORMATION *CELL PHONE CARRIER __________________________________________ ___________________________________________________ _______________________________________________________ DAD’S NAME DAD □ STEP DAD □ MOM’S NAME MOM □ STEP MOM □ ___________________________________________________ _______________________________________________________ ADDRESS ADDRESS ___________________________________________________ _______________________________________________________ DAD’S CELL PHONE # MOM’S CELL PHONE # ___________________________________________________ _______________________________________________________ DOB SOCIAL SECURITY # DOB SOCIAL SECURITY # ___________________________________________________ _______________________________________________________ EMPLOYER EMPLOYER ___________________________________________________ _______________________________________________________ WORK PHONE NUMBER WORK PHONE NUMBER ___________________________________________________ _______________________________________________________

E-MAIL ADDRESS - May we add you to our email list? __yes ___no E-MAIL ADDRESS - May we add you to our email list? __yes ___no

EMERGENCY CONTACT (FRIEND OR RELATIVE)

______________________________________________________________________________________________________________________________________

NAME RELATIONSHIP HOME PHONE CELL PHONE

REFERRED BY: ________________________________________________________________________________________________________

CONTINUE ON BACK >>>>>>>>>

INSURANCE INFORMATION

PRIMARY INSURANCE

_______________________________________________________________________________________________________________________________________ POLICY HOLDER’S NAME DOB SSN COPAY

_______________________________________________________________________________________________________________________________________ PRIMARY INSURANCE CO. POLICY NUMBER GROUP NUMBER

SECONDARY INSURANCE

_______________________________________________________________________________________________________________________________________

POLICY HOLDER’S NAME DOB SSN COPAY

_______________________________________________________________________________________________________________________________________

SECONDARY INSURANCE CO. POLICY NUMBER GROUP NUMBER

FORMS/SERVICE FEES FORMS

Fees will be charged for the following forms if not requested at the time of an office visit: • Blue Card - $5

• Camp & Sports Physicals Forms - $10

• School Medication Authorization Forms - $5

• FMLA or Disability Forms - $15

• Letters requested by patients - $5

(ALL FORM FEES WILL BE DUE AT THE TIME OF PICKUP.)

Rush Form Fee:

If a form is needed in less than 24 hrs. the form fee will be doubled.

SERVICES

• Nurse/Lab visits which are non-physician visits - $15

(Weight checks, immunization updates, allergy shots, and labs.)

• No-Show Appointments - $50

• Minimum $25 charge for any after-hours physician call not related to an office visit

PLEASE READ AND SIGN AUTHORIZATION AND ASSIGNMENT

*ALL COPAYS OR CO-INSURANCES ARE DUE AT THE TIME OF SERVICE. I (We), the undersigned, hereby agree to pay all amounts and charges hereafter incurred by me or members of my family for services

rendered by this office. In the event of non-payment, either by insurance or by me, the balance due will increase and will include a

monthly 1.5% finance charge and may include attorney and/or collection fees. Collection proceedings may result in permanent

dismissal.

I acknowledge and agree that Pediatric Associates of Madison, P.C., and any affiliates or vendor thereof, including collection or

billing companies, may contact me by telephone or text message to any telephonic number I have provided to you, and any other

telephone number associated with my account, including wireless or mobile telephone numbers. I further agree that you may use any

method of contact to these numbers, such as an Automated Telephone Dialing System (ATDS) or prerecorded message. I also agree

that I will notify Pediatric Associates of Madison, P.C., if I have given up ownership or control of any such telephone number.

CONSENT FOR TREATMENT I authorize the doctors of Pediatric Associates of Madison, P.C., to treat my minor children listed above as they deem medically

necessary. I authorize emergency medical treatment for the above-named child(ren) in the event that he/she is brought into this

practice by any person other than myself.

___________________________________________________________________________________________________________

SIGNATURE OF PARENT OF LEGAL GUARDIAN PRINT NAME DATE

APPOINTMENTS We ask that you call to schedule appointments, as

this is not a walk-in clinic. We strive to adhere to

our office schedule as much as possible and

request that you arrive for your appointments on

time. Unfortunately, delays do occur. We attempt

to remind all patients of pre-scheduled

appointments. We will call the home number to

remind; however, it is difficult for us to always be

sure of confirmation by phone. Please do not

depend on us to call and remind you. Please mark

your calendars. We require a 24-hour notification for checkup cancellations. Failure to do so will

result in a $50.00 missed appointment fee. Failure

to show for any appointment will result in a $50.00

missed appointment fee.

PRESCRIPTIONS Prescriptions and refills are issued during regular

hours, Monday-Friday (8:00a.m-4:30p.m) Our

nursing staff will call in prescription refills as time

permits. Routine prescription refills should be

requested no less than 24 hours prior to the date

required. Please do not wait until your child’s last dose of medicine to call for a refill. ADHD Medication: We require 72-hour notification for all ADHD prescription refills.

OFFICE HOURS/ EMERGENCIES Our office hours are Monday-Friday from 8:00a.m-

4:30p.m closed for lunch (12:15p.m-1:15p.m) We are

closed on weekends and major holidays: New Years Day,

Memorial Day, July 4th, Labor Day, Thanksgiving Day,

and Christmas Day. If you need emergency care at any

time, please call 911 or go to the Pediatric E.R. at

Women’s and Children’s Hospital or your nearest E.R. If

you need urgent medical advice after hours please call

(256) 772-2037 and the answering service will have the on-call physician return your call. We currently share weekend call with Twickenham Pediatrics and Hazel Green Pediatrics. Please remember to call during regular office hours for all non-urgent medical calls.

TELEPHONE CALLS

Our primary responsibility is to the patients

who are in the office seeking medical care.

Phone messages are returned by our nursing

staff on a daily basis when time permits,

based on the urgency of the call. When

leaving a message, include telephone number(s)

where you can be reached over the next

several hours. WE RETURN CALLS FROM

MULTIPLE OUTGOING PHONE LINES, SO

YOUR CALLER I.D. MAY NOT DISPLAY OUR

MAIN NUMBER; HOWEVER, INCOMING

CALLS WILL ONLY BE RECEIVED ON OUR

MAIN NUMBER (256) 722-2037. IF YOUR

CHILD HAS A LIFE-THREATENING

EMERGENCY, PLEASE CALL 911.

Exciting new website: healthychildren.org

This Children’s Healthcare website is offered

by the AAP and includes a symptom-based

application to help parents determine the

appropriate action to take: whether to treat

a child at home or take him/her to the doctor

or ER.

It is the policy of Pediatric Associates of

Madison physicians that your child(ren)

receive all immunizations and checkups

recommended by the AAP. Failure to comply

with this recommendation will result in

dismissal from our practice for non-

compliance.

GENERAL INFORMATION

Immunization/Checkup Schedule

2 week 2 months 4 months

6 months 9 months 12 months

15 months 18 months 2 years

3 years 4 years

…and checkups every year thereafter. If

your child needs a yearly physical, please

schedule this visit during the spring or

summer.

Please schedule your next checkup when

leaving the office. Yearly checkups are

scheduled at least 3 months in advance.

Immunizations and allergy shots are given on

Tuesday, Wednesday, and Thursday from

9:00 a.m. to 11:30 a.m. and 1:30 p.m. to 4:00

p.m. with a nurse appointment.

Service fees will be charged for the following:

Physician calls that are not related to an

office visit.

Prior authorizations (phone or written) for

medications-$5.00.

Letters requested by patients to agencies-

$5.00 per page.

FMLA and disability forms-$10.00.

Sports physical forms-$10.00.

Medicine forms-$5.00 per form.

Blue cards-$5.00 each.

Rush fee-If forms are needed in less than 24

hours, the above fees will be doubled.

If the above forms are completed at the

office visit, there is no charge.

A nurse fee of $10.00 is charged for the

following services:

Any nurse visit (weight check, immunizations,

allergy shots, etc.).

Lab draws (without same-day appointment).

Medical Records for Second Copy:

$5.00 search fee.

$1.00 per page for the first 25 pages.

$0.50 per page thereafter.

IMMUNIZATION POLICY

It is the policy of all Pediatric Associates of Madison physicians that your child(ren)

receive all immunizations recommended by the Advisory Committee on

Immunization Practices (ACIP) of the Center for Disease Control and Prevention

(CDC) and the American Academy of Pediatrics (AAP).

Immunization Schedule

2 and 4 months *Pediarix, HIB, Prevnar, and Rotateq

6 months *Pediarix, Prevnar and Rotateq

12 months HIB, Prevnar and Hepatitis A

15 months MMR , Varivax

18 months DTaP, Hepatitis A

4- 5 years *Kinrix, MMR and Varivax

11-12 years TdaP ,Meningitis A and HPV

16-18 years Meningitis A, Meningitis B

*Pediarix includes DTaP, IPV, Hepatitis B

*Kinrix includes DTaP, IPV

I acknowledge the receipt of the immunization policy of Pediatric Associates of

Madison, and I agree to comply with this vaccine schedule.

____________________________________________ __________________

Parent/Guardian Date

Name ________________________________ DOB _________________ Today’s Date ____________ BIRTH HISTORY: (please circle all that apply) vaginal caesarean Pre-term ___________weeks full term weight _____________ breast bottle Complications: ___________________________________________________ FAMILY HISTORY: (please circle all that apply) Diabetes Bleeding Problems Cancer Heart Disease Mental Illness High Cholesterol Seizures / Epilepsy Allergies Maternal Height ________ Paternal Height _______ PAST MEDICAL HISTORY: (please circle all that apply) Chickenpox Pneumonia Wheezing Seizure / Loss of consciousness Eczema Vision problems Broken bones Bedwetting Kidney / bladder problems Development / Behavior problems SURGICAL HISTORY: (please list all previous procedures) ______________________________________ ______________________________________ SOCIAL HISTORY: (please circle all that apply) Patient lives with: Mother Father Siblings ___________ Other: ___________ Pets smoke exposure Attends daycare / school Guns in home DAILY MEDICATIONS / HERBS / SUPPLEMENTS: (if so, please list) _____________________________________________ _____________________________________________ _____________________________________________

Pediatric Associates of Madison 21 HUGHES RD. SUITE 2 MADISON, AL 35758

(256)772-2037 FAX (256) 772-9523

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

Each Patient Must Have a Separate Release Form

PLEASE PRINT CLEARLY DATE:___________________ Patient Name: ____________________________________ Date of Birth: ____________________ Please Check One: Send Records to □ Obtain Records From □ Person/ Organization:______________________________________________ Street Address: ______________________________________________________________ City: ___________________________________ State:_______________ Zip: ___________ Phone No:_______________________________ Fax No:_____________________________ Information to be sent or received: (check all that apply) _______Immunizations _______Problem List _______Growth Charts _______Other /Specify: _______________________________________________________ Purpose of Disclosure: ________ Leaving Practice ________Specialist Referral ________ Personal Use _________ Insurance Purposes ________ Relocating/Transfer A $10 RETRIEVAL FEE AND A FEE OF .50 PER PAGE WILL BE CHARGED FOR ANY RECORDS THAT HAS TO BE RETRIEVED FROM STORAGE. I hereby Release and Authorize Pediatric Associates of Madison, P.C. to Release the Medical Records of the dependent listed (or self 18 or over) including diagnosis, treatment, prognosis, and recommendation, as well as other data pertinent to patient’s treatment to the following location listed above. I hereby state that I am the child’s parent or court appointed legal guardian and have the legal right to make and/or restrict healthcare decisions regarding this child, and that my parental authority has not been terminated or restricted by the courts. I understand that is authorization will expire twelve months from the date signed. __________________________________________________________ ____________________________________________ Signature Date Relationship to child: _________________________________________________________________________ NOTE: We ask that we be allowed 10 to 14 working days to process a release of medical information.

Limited Patient Authorization for Disclosure of Protected Health Information Please print all information. Form must be signed and dated. Patients Name Date Of Birth _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Entity Requested to Release Information: Pediatric Associates Of Madison

Purpose of request (who will be authorized to receive information) - I authorize the entity identified above to disclose or provide protected health information, about me to the individual(s) listed below. Who will be authorized to receive information (the individual(s) who is to receive your PHI): __________________________________________________Relation_______________________ __________________________________________________Relation_______________________ __________________________________________________Relation_______________________

Description of information to be disclosed - I authorize the practice to disclose the following protected health information about me to the person, or persons identified above: Entire patient record; or, check only those items of the record to be disclosed: ___office notes ____lab results, pathology reports ___x-rays ___financial history report (previous 3 years only).

In Accordance to Alabama State Law, when a minor reaches the age of fourteen, we cannot discuss the child’s private medical information with a parent without the child present or without written consent from the child. The exception is as follows: if a child seeks medical treatment and wishes to use the parent’s insurance policy, it is the policy holder’s right to know what services their insurance company has been billed for. If the child does not wish for the policy holder to be given that information, they must pay cash up front for that visit.

This authorization will expire at the end of the calendar year, unless you specify an earlier termination. You must submit a new authorization form after the expiration date to continue the authorization. Please list the date of expiration if earlier than the end of the calendar year:________________________ You have the right to terminate this authorization at any time by submitting a written request to our Privacy Manager. Termination of this authorization will be effective upon written notice, except where a disclosure has already been made based on prior authorization. The practice places no condition to sign this authorization on the delivery of healthcare or treatment. We have no control over the person(s) you have listed to receive your protected health information. Therefore, your protected health information disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule, and will no longer be the responsibility of the practice. __________________________________________________________________________________ patient or authorized representative signature date You have the right to receive a copy of signed authorizations upon request.

New Baby Information

Mother Father

Name________________________________ Name ______________________________

DOB _________________________________ DOB _______________________________

Cell __________________________________ Cell ________________________________

Email _________________________________ Email _______________________________

Pregnancy History

Obstetrician __________________________ Delivery Hospital _________________________

Previous miscarriages _____Yes _____No Plans to Feed: ____Breast ____Bottle

Previous Breast Surgery ____Yes _____No Previous Problems Breastfeeding ___Yes ___No

Problems during this pregnancy? Have you been referred to a high-risk OB? Any abnormalities on an ultrasound?

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Family History (include yourselves, parents, current children, and your siblings)

Maternal Side Paternal Side

Food Allergies ____________________________ _____________________________

Asthma ____________________________ _____________________________

Congenital Heart Disease ____________________________ _____________________________

Other Birth Defects ____________________________ _____________________________

Severe Newborn Jaundice ____________________________ _____________________________

Frequent urinary tract infections____________________________ _____________________________

Strabismus (lazy eye)/Astigmatism__________________________ _____________________________

Sudden Infant Death Syndrome ____________________________ ______________________________

Congenital Hip Dysplasia ____________________________ ______________________________

Seizures ____________________________ ______________________________

Bleeding/Clotting Problems ____________________________ ______________________________

Print this for your files. It is not necessary to bring this information to our office.

Monday: 8:00 AM - 4:30 PM

Tuesday: 8:00 AM - 4:30 PM

Wednesday: 8:00 AM - 4:30 PM

Thursday: 8:00 AM - 4:30 PM

Friday: 8:00 AM - 4:30 PM

Saturday: Closed

Sunday: Closed

APPOINTMENTS

We ask that you call to schedule appointments, as this is not a walk-in clinic. We strive to adhere

to our office schedule as much as possible and request that you arrive for your appointments on

time. Unfortunately, delays do occur. We attempt to remind all patients of pre-scheduled

appointments. We will call the home number to remind; however, it is difficult for us to always be

sure of confirmation by phone. Please do not depend on us to call and remind you. Please mark

your calendars. We require a 24-hour notification for checkup cancellations. Failure to do so will

result in a $50.00 missed appointment fee. Failure to show for any appointment will result in a

$50.00 missed appointment fee.

PRESCRIPTIONS

Prescriptions and refills are issued during regular hours, Monday-Friday (8:00 a.m.-4:30 p.m.).

Our nursing staff will call in prescription refills as time permits. Routine prescription refills should

be requested no less than 24 hours prior to the date required. Please do not wait until your child’s

last dose of medicine to call for a refill.

OFFICE HOURS/EMERGENCIES

Our office hours are Monday-Friday from 8:00a.m.-4:30 p.m., closed for lunch (12:15 p.m.-1:15

p.m.). We are closed on weekends and major holidays: New Year’s Day, Memorial Day, July 4th,

Labor Day, Thanksgiving Day, and Christmas Day. If you need emergency care at any time, please

call 911 or go to the Pediatric E.R. at Women’s and Children’s Hospital or your nearest E.R. If

you need urgent medical advice after hours please call 256-772-2037 and the answering service

will have the on-call physician return your call. We currently share weekend call with Twickenham

Pediatrics and Hazel Green Pediatrics. Please remember to call during regular office hours for all

non-urgent medical calls.

TELEPHONE CALLS

Our primary responsibility is to the patients who are in the office seeking medical care. Phone

messages are returned by our nursing staff on a daily basis when time permits, based on the urgency

of the call. When leaving a message, include telephone number(s) where you can be reached over

the next several hours. WE RETURN CALLS FROM MULTIPLE OUTGOING PHONE LINES,

SO YOUR CALLER I.D. MAY NOT DISPLAY OUR MAIN NUMBER; HOWEVER,

INCOMING CALLS WILL ONLY BE RECEIVED ON OUR MAIN NUMBER 256-772-2037.

IF YOUR CHILD HAS A LIFE-THREATENING EMERGENCY, PLEASE CALL 911.

INSURANCE/CO-PAYMENTS

It is the patient’s responsibility to know their insurance coverage. Parents of newborns must call

their insurance company and register their newborn as soon as he/she is born. Your insurance

company will not automatically add them to your policy. Co-payments are expected at the time of

service and may be paid by cash, check, or credit card (VISA and Mastercard). For those with

insurance providers with whom we do not participate, payment is due in full at the time of service.

Questions regarding your account should be directed to our billing service: (256) 772-4072. It is

the policy of Pediatric Associates of Madison physicians that your child(ren) receive all

immunizations and checkups recommended by the AAP. Failure to comply with this

recommendation will result in dismissal from our practice for non-compliance.

GENERAL INFORMATION

Immunization/Checkup Schedule

2 week 2 months 4 months

6 months 9 months 12 months

15 months 18 months 2 years

3 years 4 years

…and checkups every year thereafter. If your child needs a yearly physical, please schedule this

visit during the spring or summer. Please schedule your next checkup when leaving the office.

Yearly checkups are scheduled at least 3 months in advance.

Immunizations are given Monday through Friday from 9:00 a.m. to 11:30 a.m. and 1:30 p.m. to

4:00 p.m. with a nurse appointment.

Service fees will be charged for the following:

After-hours physician calls that are not related to an office visit-minimum $22 (based on time of

call).

Prior authorizations (phone or written) for medications-$5.00.

FMLA and disability forms-$15.00.

Sports physical forms-$10.00.

Medicine forms-$5.00 per form.

Blue cards-$5.00 each

A nurse fee of $15.00 is charged for the following services:

Any nurse visit (weight check, immunizations, allergy shots, etc.).

Lab draws (without same-day appointment).

Medical Records for Second Copy:

$5.00 search fee.

$1.00 per page for the first 25 pages.

$0.50 per page thereafter.