New Patient Registration

Please fill this form so we can get you through faster at your first appointment.

Patient name:
Patient's Sex(Required)
MM slash DD slash YYYY
Patient's Address(Required)

Pharmacy Name (Optional)
Referring Physician

PARENT/GUARDIAN INFORMATION

At least 1 parent's information must be filled in.
Name
MM slash DD slash YYYY
Address
Address (Only if Different from Patient)
Employer

EMERGENCY CONTACT

Please add a contact that isn't a Guardian.
Emergency Name(Required)
Emergency Relationship to Patient(Required)

INSURANCE INFORMATION

Please fill in information if available.
Primary Insurance Provider
Primary Insurance Provider
MM slash DD slash YYYY
Primary Holder Relationship to Patient
Primary Employer
Primary Claim Mailing Address
Secondary Insurance Provider
Secondary Holder Name
Secondary Holder Relationship to Patient
Secondary Employer
Secondary Claim Mailing Address

PAYING INSURANCE BENEFITS

I HEREBY ASSIGN ALL MEDICAL AND/OR SURGICAL BENEFITS, TO WHICH I AM ENTITLED, INCLUDING MEDICARE, PRIVATE INSURANCE AND ANY OTHER HEALTH PLANS TO PEDIATRIC HEALTH SPECIALISTS. THIS ASSIGNMENT IS FOR SERVICES RENDERED TO ME BY PEDIATRIC HEALTH SPECIALISTS THIS ASSIGNMENT WILL REMAIN IN EFFECT UNTIL REVOKED BY MYSELF IN WRITING. I HEREBY AUTHORIZE SAID ASSIGNEE TO RELEASE ALL INFORMATION NECESSARY TO SECURE THIS PAYMENT. I UNDERSTAND THAT FAILURE TO NOTIFY PEDIATRIC HEALTH SPECIALISTS OF ANY CHANGES OF INSURANCE COVERAGE WILL RESULT IN THE FINANCIAL OBLIGATION TO REST FULLY ON MYSELF REGARDLESS OF ANY CONTRACT BETWEEN THE INSURANCE COMPANY AND PEDIATRIC HEALTH SPECIALISTS.
Patient Name(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY

HIPAA DISCLOSURE

I UNDERSTAND THAT, UNDER THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA), I HAVE CERTAIN RIGHTS TO PRIVACY REGARDING MY PROTECTED HEALTH INFORMATION. PROTECTED HEALTH INFORMATION (PHI) MAY ORIGINATE IN YOUR MEDICAL RECORD AT PEDIATRIC HEALTH SPECIALISTS, OR MAY BE RECEIVED FROM OUTSIDE HEALTH ENTITIES AND FILED IN YOUR MEDICAL RECORD. I UNDERSTAND THAT THIS INFORMATION CAN AND WILL BE USED BY PEDIATRIC HEALTH SPECIALISTS TO: A) CONDUCT, PLAN AND DIRECT MY TREATMENT AND FOLLOW-UP AMONG THE MULTIPLE HEALTHCARE PROVIDERS WHO MAY BE INVOLVED IN THE TREATMENT DIRECTLY OR INDIRECTLY B) OBTAIN PAYMENT FROM THIRD-PARTY PAYERS C) CONDUCT NORMAL HEALTHCARE OPERATIONS SUCH AS QUALITY THROUGH PEDIATRIC HEALTH SPECIALISTS OR NETWORKING ORGANIZATIONS, AND D) CONSENT TO PROPERTY TRANSFER OF SPECIMEN (TISSUE OBTAINED DURING MEDICAL TESTING) TO PEDIATRIC HEALTH SPECIALISTS. I HAVE BEEN INFORMED BY YOU OF YOUR NOTICE OF PRIVACY PRACTICES CONTAINING A MORE COMPLETE DESCRIPTION OF THE USES AND DISCLOSURES OF MY HEALTH INFORMATION. I UNDERSTAND THAT THIS ORGANIZATION HAS THE RIGHT TO CHANGE ITS NOTICE OF PRIVACY PRACTICES FROM TIME TO TIME AND THAT I MAY OBTAIN A CURRENT COPY OF THE NOTICE OF PRIVACY PRACTICES FROM MY OFFICE OR BY CONTACTING THEM AT PEDIATRIC HEALTH SPECIALISTS, MEDICAL CITY LAS COLINAS, MEDICAL PLAZA, SUITE 303, 6750 NORTH MACARTHUR BLVD, IRVING, TX 75039. I UNDERSTAND THAT I MAY REQUEST IN WRITING THAT YOU RESTRICT HOW MY PRIVATE INFORMATION IS USED OR DISCLOSED FOR TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS. I ALSO UNDERSTAND THAT YOU ARE NOT REQUIRED TO AGREE TO MY REQUESTED RESTRICTIONS, BUT IF YOU DO AGREE THEN YOU ARE BOUND TO ABIDE BY SUCH RESTRICTIONS. I UNDERSTAND THAT I MAY REVOKE THIS CONSENT IN WRITING AT ANY TIME, EXCEPT TO THE EXTENT THAT YOU HAVE TAKEN ACTION RELYING ON THIS CONSENT.
Patient Name(Required)
MM slash DD slash YYYY
Email Consent(Required)
Text Consent(Required)
MM slash DD slash YYYY

ImmTrac2, the Texas Immunization Registry Consent for Registration of Child and Release of Immunization Records to Authorized Entities.

The Texas Department of State Health Services encourages your voluntary participation in the Texas immunization registry. ImmTrac2, the Texas immunization registry, is a free service of the Texas Department of State Health Services (DSHS). The immunization registry is a secure and confidential service that consolidates and stores your child’s (younger than 18 years of age) immunization records. With your consent, your child’s immunization information will be included in ImmTrac2. Doctors, public health departments, schools, and other authorized professionals can access your child’s immunization history to ensure that important vaccines are not missed. I understand that, by granting the consent below, I am authorizing release of the child’s immunization information to DSHS and I further understand that DSHS will include this information in the state’s central immunization registry (“ImmTrac2”). Once in ImmTrac2, the child’s immunization information may by law be accessed by: · a public health district or local health department, for public health purposes within their areas of jurisdiction; · a physician, or other health-care provider legally authorized to administer vaccines, for treating the child as a patient; · a state agency having legal custody of the child; · a Texas school or child-care facility in which the child is enrolled; · a payor, currently authorized by the Texas Department of Insurance to operate in Texas, regarding coverage for the child. I understand that I may withdraw this consent to include information on my child in the ImmTrac2 Registry and my consent to release information from the Registry at any time by written communication to the Texas Department of State Health Services, ImmTrac Group – MC 1946, P. O. Box 149347, Austin, Texas 78714-9347. Privacy Notification: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect By my signature below, I GRANT consent for registration. I wish to INCLUDE my child’s information in the Texas immunization registry.
MM slash DD slash YYYY

RELEASE OF INFORMATION

Please choose one option.
(Required)
Release Allowed to Name 1
Release 1 Relationship
Release Allowed to Name 2
Release 2 Relationship
Release Allowed to Name 3
Release 3 Relationship