CONSENT TO TREAT Notice of Privacy Practices Acknowledgement I acknowledge that Pediatric Neurology Center provided me with a written copy of his/her Notice of Privacy Practices. I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions. (Please initial) General Consent to Treat I am the parent/guardian of I have the legal right to consent to medical & surgical treatment for the patient. I voluntarily authorize and consent to the medical care, treatment and diagnostic tests that Pediatric Neurology Center and its designated associates or assistants believe are necessary for this child. I understand that by signing this form, I am giving permission to the doctors, nurses, physician assistants and other healthcare providers in this medical office to provide treatment to this child as long as this child is a patient in this office, or until I withdraw my consent (Please initial) Consent to Release and Obtain Information In agreement with federal and state law, I agree to allow Pediatric Neurology Center to provide necessary care to this child in order to provide continuity of care and treatment Pediatric Neurology Center and/or the patient’s provider may obtain from any source and examine use, or discuss and disclose, the patient’s medical record and information to treating hospital personnel and agents, other healthcare providers, medical records auditors, professional committees, care evaluators and governmental agencies. This information can include, but is not limited to: medical history, examinations, diagnoses, treatments any psychiatric, drug and alcohol abuse or genetic testing information, or HIV or AIDS information. This consent to release and obtain information is valid until revoked. The undersigned may revoke the consent in writing at any time, except with regard to disclosures that have already been made in reliance on such consent. (Please initial) Electronic Prescriptions (E-Prescribing) I voluntarily authorize the Pediatric Neurology Center to allow EPrescribing for the patient's prescriptions. This allows healthcare providers to transmit prescriptions to the pharmacy of my choice electronically, and review pharmacy benefit information and medication dispense history as long as this child is a patient at this office, or until I withdraw my consent. (Please initial) I have read this form, or this form has been read to me in a language that I understand, and have had an opportunity to ask questions about it. (Please initial) Name of Patient: Patient’s Date of Birth: MM slash DD slash YYYY Guardian’s Name: Relationship to Patient: Guardian’s Signature:Date: MM slash DD slash YYYY Pediatric Neurology Center OFFICE POLICIES AND PROCEDURES To answer your questions and improve our efficiency, we have compiled the following office policy. OFFICE HOURS: 8:00 am-5:00 pm (Monday- Friday, Sat 9:00 am – 12:00 pm). When calling for an appointment, please tell us the nature of the problem. More acute/severe cases are given priority. We make every effort to keep on schedule. Delays can occur. Please help us keep on schedule by arriving for your appointment 15 minutes before your appointment time. If you arrive more than 15 minutes late for your appointment, we may have to reschedule the visit. If it is necessary for you to cancel your appointment, you must give us twenty-four hours’ notice. If you do not cancel your new patient appointment at least 24 hours in advance, we may not permit you to reschedule. In addition, there may be a charge for follow-up appointments canceled less than 24 hours in advance. THE ROLE OF THE REFERRING PHYSICIAN: Since this is a practice in consultative Pediatric Neurology, each child must have a primary care physician, general pediatrician or family doctor. Your child's primary care physician will be kept informed of your child's progress and current neurological status. Your primary care physician is the doctor you should contact for your child's routine care. AFTER OFFICE HOURS: The phone is answered after hours 7 days a week via voice mail system. Instructions are given to leave a message which will be returned the next business day. If it is an emergency, please call 911 or go to your local ER. If you subscribe to "Caller ID" and "Anonymous Call Rejection", please be advised that most phones utilized by our doctor have caller ID blocking and will reflect "anonymous" or "private" when your phone calls are returned. Be aware that this could cause a problem if the doctor needs to reach you with information regarding your child. Prescription refills are not handled after hours. MEDICATION: Requests for medication refills should be called in during regular office hours. Please do not request refills for medications after hours. Keep track of your supply of medication and request refills before running out. Note the date on the prescription; you have 21 days to have it filled. MEDICAL RECORDS: Letters and narrative reports are routinely sent to the primary care physician after your visit. We require written consent from a parent or a guardian prior to sending medical records to anyone other than your primary care physician. NO INFORMATION REGARDING PATIENTS WILL BE RELEASED TO ANYONE WITHOUT A WRITTEN AUTHORIZATION FROM THE PARENT OR GUARDIAN. Guardian’s Name: Relationship to Patient: Guardian’s Signature:Date MM slash DD slash YYYY Patient’s Name: Date of Birth: MM slash DD slash YYYY Pediatric Neurology Center FINANCIAL POLICY Updated 01/2024 At the Pediatric Neurology Center, we are committed to providing quality care and we are pleased to discuss our fees for professional services with you at any time requested. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about this financial policy. FINANCIAL POLICY STATEMENT We bill your insurance carrier solely as a courtesy to you. If you are enrolled in a plan we have a contract with, you are only required to pay the co-payment/deductible/co-insurance at the time of your visit provided you bring your referral, if needed, with you before or on the day of your visit. We require that arrangements for payment of your estimated share be made before being seen by the physician. If your insurance carrier does not remit payment within 45 days, the balance will be due in full from you. If your insurance company requests a refund of payments made, you will be responsible for the amount of money refunded to your insurance company. In the event your company establishes an internal usual and customary fee schedule, you will be responsible for the difference remaining. If any payment is made directly to you for services billed to us, you recognize an obligation to promptly remit the same payment to the Pediatric Neurology Center. This does not apply for those patients that are on an HMO plan or considered Worker’s Compensation. UNACCOMPANIED MINORS: Minor must have authorization for medical treatment signed by his/her parent/guardian and is responsible for providing current insurance information for self. Please note that co-payments and/or deductibles are expected at the time of service. REGARDING DIVORCE: Pediatric Neurology Center does not get involved in disputes between divorced parents regarding financial responsibility for their child’s medical expenses. Payment is the responsibility of the parent who brings the child to the office for treatment. This is regardless of the terms outlined in a divorce decree. This is a matter between the divorced parties and the courts, and we cannot be placed in the middle. If divorced parents cannot agree on treatment for their child, we may not be able to continue to treat them. REGARDING INSURANCE: Indemnity/Fee for Service: We require full payment at the time of service. We will supply you with a copy of your itemized statement so that you can file for reimbursement from your insurance company. Should your insurance company require a more detailed description of services, please have them request it in writing. REGARDING HSA/HSR: We DO NOT collect from HSA/HSR accounts. If it is paid through your insurance, we will immediately refund you once we receive payment. REGARDING BEING LATE: Arrival greater than 15 minutes after appointment time will result in the option to reschedule or be seen in the next available time slot if one is available. If no time slot is available, you will need to reschedule. APPOINTMENT CANCELLATION/NO-SHOWS: Failure to provide 24 hours notice when canceling said appointments, or not showing up for your appointment will result in a $50 fee being assessed, as these appointment times could have been given to another patient(s) in need. Please be advised that reminder phone calls and emails are made as a courtesy to you and do not relieve you of the responsibility for remembering your child’s appointment. We DO NOT ACCEPT SECONDARY INSURANCE, third-party insurance, social security or auto accident claims. We only accept and file with your primary insurance. If you require a referral number from your insurance carrier, please understand that this is your responsibility as the insured to obtain this from your PCP and not our office. Insurance is a contract between you and your company. We are not a party to your contract. We will not become involved in disputes between you and your insurance company regarding deductibles, non-covered charges, co-insurance, secondary insurance, coordination of benefits, pre-existing conditions, or “reasonable and customary” charges other than to supply the factual information as necessary. You are responsible for the timely payment of your account. I understand and agree that if I fail to make any of the payments for which I am responsible in a timely manner, I will be responsible for all costs of collecting monies owed, including court costs, collection agency fees, and attorney fees. I have read and understand that I am personally responsible for payment on this account. Assignment: I hereby authorize payment directly to the Pediatric Neurology Center. Any changes in this authorization must be received in writing within 30 days of the effective date. In the event my insurance company deems a service to be “non-covered” I understand that I am personally responsible for payment. I agree to the release of any and all medical information, including HIV test results, and financial information necessary to process this and any future claims to my insurer or payer of health benefits, as I may designate that person or entity from time to time, for an indefinite period or until I submit a written revocation of this release. Any changes to this authorization must be received in writing within thirty days of the effective date. Billing is automated and accounts over 90 days past due are automatically turned over to an agency for collection. There is a $25.00 fee if we have to turn your account over to an agency for collection. We do accept MasterCard, VISA, AMEX, and Discover for your convenience. Medicaid assignment is accepted if it is the primary insurance. These fees are not covered by your insurance plan. Guardian’s Name: Relationship to Patient: Guardian’s Signature:Date MM slash DD slash YYYY Patient’s Name: Date of Birth: MM slash DD slash YYYY Acknowledgment(Initials) You are responsible for any charges at the time of service. We DO NOT collect from HSA/HSR accounts. If it is paid through your insurance, we will refund you once we receive payment. (Initials) Late/No Show Policy: We strive to follow a strict schedule to avoid wait times. If you are more than 15 minutes late for any appointment, you will be charged a $25 late fee and have the option to reschedule or be seen in the next available time slot if one is available. If no time slot is available, you will need to reschedule.(Initials) Failure to provide 24 hours’ notice when cancelling said appointments, or not showing up for your appointment will result in a $50 fee being assessed. Please be advised that reminder phone calls are made as a courtesy to you and do not relieve you of the responsibility for remembering your child’s appointment.(Initials) We DO NOT ACCEPT SECONDARY INSURANCE, third-party insurance, social security, or auto accident claims. This is in effect for all patients, regardless of insurance carrier, and everyone is treated equally. (Initials) Every insurance plan is contracted differently, and we are not always aware of the various levels of coverage. Therefore, we are not able to anticipate the final out-of-pocket costs at the time of your visit but will do our best on the estimation.(Initials) All children must be closely supervised at all times. We want to maintain a clean, wellkept office. Please do not allow children to climb or mark on walls, chairs, tables, books, etc.(Initials) Our office requires a 48-hour notice when requesting any medication refill. NO refills are approved after hours. You are required to call during office hours to script refill requests.(Initials) I acknowledge that I have been presented with and have read and understood the Policies & Procedures provided to me by the Pediatric Neurology Center. I agree to abide by the policies of the Pediatric Neurology Center.(Initials) Insurance Carriers Requiring Referral Numbers (Medicaid, HMO, POS, EPO): If your insurance carrier requires you to have an insurance referral before you see a specialist, our office must receive the insurance referral number before your arrival. If we do not have it upon sign-in, your appointment will be rescheduled to a later date and time. In the case that we are unaware that your insurance requires a referral number and they do not cover the visit you will be responsible for any charges accrued.Guardian’s Name: Date MM slash DD slash YYYY Guardian’s Signature:CONSENT FORM FOR TAKING YOUR CHILD'S PHOTO TO BE PLACED IN THE PATIENT CHART FOR THE PEDIATRIC NEUROLOGY CENTER As the parent/guardian of, I give my permission for my child’s photo to be used in the patient chart This picture will only be used for internal records. I can request that my child’s picture be removed from the chart at any time. Signed Permission will be kept as part of your child’s medical record. Parent’s/Guardian’s SignatureDate MM slash DD slash YYYY Authorization for Non-Parent Consent for Care Name of Patient Patient’s Date of Birth MM slash DD slash YYYY I hereby authorize (when I am unavailable to give consent) to the following individual(s):Name of Person Relationship to Child Name of Person Relationship to Child to consent to any medical care and attention for this child that is deemed necessary and appropriate by a health care provider licensed in the state of Texas. The consent includes but is not limited to, medical and surgical intervention and elective as well as emergency care. This delegation shall be valid until I withdraw the delegation of consent. Parent’s/Guardian’s SignatureRelationship to Patient Date MM slash DD slash YYYY Witness Informed Consent for Telemedicine ServicesPatient Name: Date of Birth: MM slash DD slash YYYY PURPOSE: The purpose of this form is to obtain your consent to participate in a telemedicine consultation in connection with pediatric neurology and development. NATURE OF TELEMEDICINE CONSULT: During the telemedicine consultation: Details of your medical history, examinations, test results, neuroimaging/x-rays and labs will be discussed with other health professionals through the use of interactive video, audio, and telecommunication technology. A physical examination of you may take place. Video, audio, and/or photo recordings may be taken of you during the procedure(s) or service(s). MEDICAL INFORMATION & RECORDS: All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Please note, that not all telecommunications are recorded and stored. Additionally, dissemination of any patient-identifiable images or information for this telemedicine interaction to researchers or other entities shall not occur without your consent. CONFIDENTIALITY: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation, and all existing confidentiality protections under federal and Texas state law apply to information disclosed during this telemedicine consultation. RIGHTS: You may withhold or withdraw consent to the telemedicine consultation at any time without affecting your right to future care or treatment. DISPUTES: You agree that any dispute arising from the telemedicine consult will be resolved in Texas and that Texas law shall apply to all disputes. PAYMENT OF SERVICES: You agree that the Pediatric Neurology Center reserves the right to bill a telemedicine visit to your respective insurance company. Also, you are responsible for any patient portion of the telemedicine consult, before your telemedicine consult is performed. In the event your insurance does not cover the consultation, you understand that you are personally responsible for payment. RISKS, CONSEQUENCES & BENEFITS: You have been advised of all the potential risks, consequences, and benefits of telemedicine. You have had the opportunity to ask questions about the information presented on this form and the telemedicine consultation. All your questions have been answered, and you understand the written information provided above. I agree to participate in a telemedicine consultation for the procedure(s) described above. SignatureDate: MM slash DD slash YYYY PATIENT INFORMATIONDate of Visit: MM slash DD slash YYYY Patient Demographics:First and Last Name: Nickname of child: Date of Birth: MM slash DD slash YYYY Sex: Male Female Social Security #: Race: Address: Street Address City State / Province / Region ZIP / Postal Code Parent/Guardian Information:First and Last Name: Address: Street Address City State / Province / Region ZIP / Postal Code Primary Cell #:Secondary Cell #:Email: Referring Physician: PhoneFax:Primary Physician: PhoneFax:Pharmacy: NumberZip Code:INSURANCE INFORMATIONPrimary Insurance Company: Insured name (Policyholder): Relationship to patient: Policy or Group #: Identification #: Address: Street Address City State / Province / Region ZIP / Postal Code Social Security #: DOB: MM slash DD slash YYYY Sex: Employer: Address: City State / Province / Region ZIP / Postal Code Work Phone#:Untitled(Required) I hereby authorize the release of all information needed to process my insurance claims. I hereby assign and request payment directly to the Pediatric Neurology Center PLLC. I understand that I am completely responsible for all charges/amounts not covered by my insurance. Parent/Guardian Signature:Date: MM slash DD slash YYYY HEALTH HISTORY Reason/s for visit: Birth History:Delivery type: C-Section Vaginal Full Term Premature Birth Weight: Weeks at delivery: Adopted? Pregnancy/Delivery complications: Developmental History & Milestones:Smiling: Rolling over: Sitting: Crawling: Walking: Motor concerns? Yes No Speech:Age at First word: Age at 3-word sentences: Speech concerns? Yes No Were developmental skills ever lost? Any Regression? Yes No If so, explain: Sleep concerns? Yes No If so, explain: Past Medical History:Illnesses: Hospitalizations/Surgery/Procedures:Date MM slash DD slash YYYY Reason Date MM slash DD slash YYYY Reason Date MM slash DD slash YYYY Reason Drug Allergies: Are immunizations up to date? Yes No Previous Illness/Diagnosis: Yes No Diagnosis: Developmental delays Autism Attention Deficit Disorder Learning Disability Seizures/Epilepsy Migraines/Headaches Syncope Concussion injury Others Others: Medications with dose and frequency:Prior testing: Please write approximate dates of the study and results if known.MRI MRI CT HEAD CT HEAD ECG EEG Genetic testing Genetic testing Others Others Others Social History:Lives with: Name of School: Grade: School problems? Yes No 504/IEP in place? Concerns regarding school performance: Family History: Please list any known family neurological diseases/disorders:Mother: Father: Siblings: Grandparents: Aunts/Uncles/Cousins: Review of Systems:(check all that apply)NEUROLOGICAL Headaches Seizures Weakness Numbness GENERAL Fatigue Fever Recent Illness Dizziness EYES Vision Change Blurry Vision Vision Loss Eye Pain HEADS/EARS/THROAT Congestion Sore Throat Ringing in Ears Hearing Loss CARDIOVASCULAR Chest Pain Palpitations Syncope Exercise Intolerance RESPIRATORY Difficulty Breathing Wheezing Cough Snoring GASTROINTESTINAL Abdominal Pain Nausea Vomiting Constipation SKIN Rash Moles/Birthmarks Skin Lesions Nail Changes MUSCULOSKELETAL Joint Pain Joint Swelling Back Pain Muscle Pain ENDOCRINE Weight Gain Weight Loss Hair Loss Temperature Intolerance HEMATOLOGICAL Easy Brusing Nose Bleeds Bleeding Disorder Anemia PSYCHIATRIC Depression Sadness Hallucinations Anxiety
