SoFHA
Patient Forms

Patient Paperwork


Description:

The Riverside Pediatrics new patient paperwork.


Code:

2.001

Issued:

07/02/2018

Revision:

2

Revised:

N/A

Related Documentation

Notice of Nondiscrimination


Thank you for choosing Riverside Pediatrics as your child's pediatrician. The first step to becoming a patient with us is to complete a new patient packet. All forms included in the packet will need to be completed in full and given to the receptionist. At this time we will request a copy of the legal guardian's driver's license and a copy of your insurance card. Once we process your new patient paperwork you will receive a letter by mail stating the date and time of your next appointment. You will receive a text message reminder two days prior to your appointment. Please reply to this text message to confirm your appointment. If you do not confirm the appointment by text, we will try to reach you by phone. If you need to cancel your new patient appoinment, you will need to do so no less than 48 hours in advance.

If you fail to keep your new patient appointment, you will NOT be rescheduled.

Regretfully, we are not in the network with TNCARE SELECT or COVERKIDS.


Patient Information























Mother's Information














Father's Information














Family History




Does anyone in your family have a history of:


















Authorization for Disclosure of Health Information

Covering the period of healthcare from the patient's date of birth to today's date, I hereby authorize:


to disclose all of the information from the health records of the patient specified in this form to:
Riverside Pediatrics
1503 West Elk Avenue Suite 12
Elizabethton TN, 37643
P: (423) 547-9400 Fax: (423) 547-9401

I understand this authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance on this authorization. To revoke this authorization, I understand I must contact the following in writing: State of Franklin Healthcare Associates, attn: Privacy Officer, 2528 Wesley St., Suite 2, Johnson City TN, 37601. Unless otherwise revoked, this authorization will expire on the following date, event condition, or within one year from the time I submitted this form:

The facility, its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein. Please be aware that information will be released to a non-custodial parent unless we have a court order stating otherwise.


Acknowledgement of Notice of Privacy Practices

I have been given the opportunity to review the Notice of Privacy Practices and understand that the Notice describes how my protected medical information may be used and disclosed and how I may get access to this information. I have also been given the opportunity to take a copy of the Notice of Privacy Practices for further review.

If for some reason the facility needs to relay my protected medical information, i.e. lab results or billing issues, you can either leave a message with or discuss the information with the following individual(s):



















Emergency contact number other than YOUR main phone number:




Payment Policy

We are participating with Medicare, Tennessee Medicaid, and most Managed Care plans in the area. We will file these claims for you. Patients are expected to pay any deductibles, coinsurance or copay amounts owed at the time of service.

If you are a Medicare patient and do not have a supplemental plan or a Medicare Advantage plan, you are responsible for payment of the annual deductible, co-insurance and non-covered services at the time of service.

Patients with a third party coverage with whom we do not contract are responsible for payment in full at the time of service. As a courtesy, we will file your charges with this third party payer upon receipt of payment in full. Otherwise, we will provide you with a completed third party payer claim form to use in filing your insurance.

Patients with a High Deductible Health Plan that have not met their annual deductible amount on the date of service will be asked to pay SoFHA's estimate of the allowed charges at the time of service. You will be billed for any additional deductible amounts after the insurance processes the claim.

Patients without verifiable insurance will be responsible for payment of all services rendered at the time of service. We accept cash, check, Visa, MasterCard, Discover and American Express.

Please realize, however, that:

  1. Your insurance is a contract between you and your insurance company. We are not a party to that contract. You are responsible to know your insurance benefits and the portion you will be liable for.
  2. Depending on the specifics of the agreement we have with your insurance company, any portion of our fees not covered may be the responsibility of the patient.
  3. Not all services are a covered benefit in all counts. Some insurance companies arbitrarily select certain services they will not cover. Any service not covered is the responsibility of the patient.

Regardless of insurance payment the patient and/or guardian remains responsible for all financial obligations incurred at the time of service. We realize that some balances may not be able to be paid in full at time of service and we will be happy to assist you in making satisfactory payment arrangements.

This agreement will remain in effect until revoked in writing.


No-Show Policy

State of Franklin Healthcare strives to provide excellent, quality care to each and every patient in a timely manner. In an effort to provide care when you need it, we have updated our policies on missed or canceled appointments and patient discharges.

We try to be good stewards of your time and ours. So, when at all possible, please notify us as soon as possible and at least 24 hours in advance when you are unable to keep your appointment. We will assist you in selecting another time better for you and will still be able to allow someone else to be seen.

In addition, we need time to greet you and complete registration for your appointment. Therefore, we ask that you always arrive at least 15 minutes prior to your appointment. Should you be running later than 15 minutes past your appointment time, we may consider this a "no show" but will make an effort to see you.

We realize things happen and you may miss an appointment. We do track missed appointments and will notify you if this happens. Your provider determines how often you need to be seen; so, to receive proper care, you need to keep or reschedule appointments within the time frame discussed at your visit.

We never want to say goodbye to a patient but sometimes circumstances cause us to determine our relationship isn't working the way it should. If you miss or "no show" an appointment three times, you are not receiving the frequency of care you need nor are we able to use that time for another patient in need. At that point, you may be asked to establish with another provider for your care.

We feel a good relationship consists of mutual respect. However, sometimes challenges arise that may cause us to discontinue the relationship. In addition to a trend of missed appointments, other issues that qualify for dismissal include failure to comply with a prescribed treatment plan, inappropriate/ abusive behavior to providers, staff or other patients or failure to pay outstanding balances.

Please let us know if you have any questions related to our policies. We are always available to answer your questions and thank you for the privilege to participate in your care.


Consent to Treatment of a Child by Authorized Person

The undersigned parent or legal guardian of the child specified above authorizes the person(s) listed below to consent to treatment of the child, including, but not limited to, emergency, x-ray, anesthetic, or surgical services when I am not immediately available in person, or by a telephone call to my main number.

It is understood that this consent is given in advance of any specific diagnosis or treatment and allow the physician/provider to diagnose and treat the child even when the parent or guardian is not present.

Person(s), besides parents, who may consent to treatment:





















Health Leads Screening













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By typing your name in the signature field below, you consent to all of the agreements listed in this form. You furthermore agree that your submission of this form, via the "Submit Form" button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.