Welcome Packet

 

      WELCOME TO WELLNESS PEDIATRICS - (Please print)

    Patientís Name: ______________________________ Date of Birth:_________

    Gender: ____F ____M

    List all siblings:

    _______________________________ Date of Birth: _____________ Male/Female

    _______________________________ Date of Birth: _____________ Male/Female

    _______________________________ Date of Birth: _____________ Male/Female

    _______________________________ Date of Birth: _____________ Male/Female

    Ethnicity: (Data is used for statistical reporting)*

    ____ Hispanic or Latino ____Not Hispanic or Latino ____ Patient Declined

    Race: (Data is used for statistical reporting)*

    __ American Indian or Alaska Native __ Black or African American

    __ Native Hawaiian/Pacific Islander __ Asian __ White __ Declined Share

    Language: (Data is used for statistical reporting)*

    ____ English ____ Spanish _____ Other

    Familyís Email Address: ___________________________________

    Street Address: ______________________________________________________

    Town: _________________________ State: ________ Zip Code: ____________

    Parentís Name # 1:___________________________________________________

    Address if different from Patientís: _________________________________________

    Home Phone: ________________________ Cell #: ________________________

    Parentís Name # 2: ___________________________________________________

    Address if different from Patientís: ________________________________________

    Home Phone:_________________________ Cell #: _______________________

    Motherís Maiden Name: _________________ (Required by NJ Vaccine Registry)*

    Guarantorís Name and Date of Birth: (Person responsible for unpaid balances) _______________________________________________

    Patientís Primary Insurance Information:

    Policyholderís Name ___________________________Date of Birth: ___________

    Insurance Company _____________________________________________

    ID Number _____________________Group Number ___________________

    *Please be advised that our office submits confidential data of childrenís vaccinations to the NJIIS (New Jersey Immunization Information System) per the Statewide Immunization Registry Act. The purpose of this program is to keep a central record of patientís immunization history.

    Assignment of Benefits/Authorization/Notice of Collection Action

    I understand I am responsible for knowing the benefits my insurance plan provides. In doing so, it is also my responsibility to verify proof of insurance by ensuring that the office staff has the most current/valid insurance card on file. I further understand that all co-payments are due at time of service and I am also responsible to pay other amounts due; these amounts may include annual deductibles, charges denied by my insurance company as not covered or not medically necessary, and/or any fees incurred should my account require collection action. (E.G. late fees, collection agency, court or attorney costs). Also, please be advised our office may contact you via an automated system regarding appointments and/or account status. I agree this authorization shall remain valid unless/until I rescind in writing.

    WE DO NOT ACCEPT SECONDARY INSURANCE BUT WILL PROVIDE THE REQUIRED INFORMATION FOR YOU TO FILE THAT TYPE OF A CLAIM IF NECESSARY.

    Records Release Information

    A $10.00 record release fee (per child) is required when releasing records to a parent. A $15.00 record release fee (per child) is required when transferring records to another physicianís office.

    I understand that Wellness Pediatrics, LLC will need to share medical information about my child with my insurance company, my pharmacist or other members of the medical community as authorized under the Notice of Privacy Practice effective 4/14/03. I authorize Wellness Pediatrics to leave messages on my answering machine concerning appointments, test results, and other pertinent information. I understand that Wellness Pediatrics, LLC respects my confidentiality and will use professional discretion in sharing any information about my child. WELLNESS PEDIATRICS WILL BILL MY INSURANCE COMPANY AS PER THE INFORMATION PROVIDED TO THEM. I WILL BE RESPONSIBLE FOR PAYING ANY REMAINING BALANCES IN A TIMELY MANNER.

    Signature Required

    The undersigned acknowledges that I have read and understand the above terms and conditions.

    Parentís Signature: ________________________ Todayís date: _______________

    01/16/16

 

 Wellness Pediatrics, LLC

Dr. Christian Canzoniero, M.D.

Dr. Maria Gatoulis, M.D.

Dr. Rajesh Raman, M.D.

21 Lafayette Road, Suite F

Sparta, NJ 07871

Notice of Privacy Practice

To our Patients Ė THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our commitment to your privacy Ė Our practice is dedicated to maintaining the privacy of your health information. We are required by law (HIPPA Ė Health Insurance Portability and Accountability Act of 1996) to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following information:

Uses and Disclosures of Health Information

With your consent, we may use health information about you for treatment (such as sending your medical record information to a specialist physician as part of a referral, or discussing your medication with the pharmacist), to obtain payment for treatment (such as sending billing information to a health insurance plan), for administrative purposes, and to evaluate the quality of care that you receive (such as comparing patient data to improve treatment methods).

We may use or disclose identifiable health information about you without your authorization for several other reasons. Subject to certain requirements, we may give out health information without your authorization for public health purposes, abuse or neglect reporting (DYFS), auditing purposes, and emergencies. We provide information when otherwise required by law, such as for law enforcement in specific circumstances. We may also contact you about appointment reminders or treatment alternatives. In any other situation, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures.

We may change our policies at any time. Before we make a significant change in our policies, we will change our notice and post the new notice in the waiting area, in each examination room, and on our Web site. You can also request a copy of our notice at any time. You must submit your request in writing to Wellness Pediatrics LLC, Office Manager, 21 Lafayette Road, Suite F, Sparta, NJ 07871 (Fax 973-726-8445).

Individual Rights

In most cases, you have the right to look at or get a copy of health information about you that we may use to make decisions about you. If you request copies, we will charge you $0.05 (5 cents for each page) with a minimum of $5.00 per patient. You also have the right to receive a list of instances where we have disclosed health information about you for reasons other than treatment, or related administrative purposes. If you believe that information in your record is incorrect or if important information is missing, you have the right to request that we correct the existing information or add the missing information.

You have the right to request that your health information be communicated to you in a confidential manner such as sending mail to an address other than your home. If this notice was sent to you electronically, you may obtain a paper copy of the notice.

You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends.

Complaints

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the person listed below. You may also send a written complaint to the U.S. Department of Health and Human Service, Hubert H. Humphrey Building, 200 Independence Avenue S.W., Washington, DC 20201. Under no circumstance will you be retaliated against for filing a complaint.

Our Legal Duty

We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices that are described in this notice.

If you have any questions or complaints, please contact: Wellness Pediatrics, LLC, Attn: Office Manager, 21 Lafayette Road Suite F, Sparta, NJ 07871, (973) 726-4455

Effective Date of Notice

This notice is effective on April 14, 2003.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

     WELLNESS PEDIATRICS, LLC

    NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT

    I hereby acknowledge that I have been presented with a copy of Wellness Pediatricsí Notice of Privacy Practice.

    PRINTED NAME OF PATIENT(S): ___________________________________

    ____________________________ ________________________________

    ____________________________ ________________________________

    PARENT SIGNATURE IF UNDER 18 YEARS OLD:

    ______________________________________

    DATE: _______________________________

 

 TREATMENT FOR MINORS

Many times, parents and /or guardians find themselves unable to accompany their teens or young adult children to appointments. This form has been prepared for your convenience should you at some time be unable to accompany your child.

I hereby grant Wellness Center Pediatrics permission to treat my child when he/she arrives at the office unaccompanied.

__________________________________ ___________________

Signature of Parent/Legal Guardian Date