SoFHA
Patient Forms

Patient Paperwork


Description:

The Riverside Pediatrics new patient paperwork.


Code:

2.001

Issued:

07/02/2018

Revision:

4

Revised:

05/06/2019

Related Documentation

Notice of Nondiscrimination


We are currently not accepting new patients. Please call our office for details: (423) 547-9400

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.


Patient Information























Mother's Information














Father's Information














Guardian's Information















Family History




Does anyone in your family have a history of:


















Authorization for Use or Disclosure of Protected Health Information

I hereby authorize State of Franklin Healthcare Associates, PLLC to request the following information:

  • Full Name
  • Date of Birth
  • Phone Number
  • Last 4 of SSN

Person(s) or Entity Authorized to Receive the Disclosure. Name or specifically describe the persons/organizations (or the classes of persons and/or organizations), including us, (1) who you are authorizing to make use of the protected health information described below and who you are authorizing to disclose the protected health information described below, and (2) to whom you are authorizing the disclosure and subsequent use of the protected health information described below.

TO:






FROM:







Protected Health Information to be used or disclosed. Specifically and meaningfully describe the protected health information you are authorizing to be used and/or disclosed:


My health information related to psychiatric or psychological conditions or treatment, except psychotherapy notes; alcohol and drug abuse; sickle cell anemia; and acquired immune deficiency syndrome (AIDS) or human immunodeficiency virus (HIV).



Purpose of use or disclosure:





Authorization and Signature: I authorize the release of my confidential protected health information, as described in my directions above. I have had the opportunity to read and consider the contents of this authorization. I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions. I further understand that refusing to sign this authorization will not affect my treatment, payment, enrollment, or eligibility for benefits. I understand that I may revoke this authorization in writing, except for any actions already taken based upon it. The information that is used and/or disclosed pursuant to this authorization may be redisclosed by the recipient unless the recipient is covered by federal or state laws that limit the use and/or disclosure of my confidential protected health information.

The following specifies your rights about this authorization under the Health Insurance Portability and Accountability Act of 1996, as amended from time to time ("HIPAA").

  1. Tell your provider if you do not understand this authorization, and the provider will explain it to you.
  2. You have the right to revoke or cancel this authorization at any time, except: (a) to the extent information has already been shared based on this authorization; or (b) this authorization was obtained as a condition of obtaining insurance coverage. To revoke or cancel this authorization, you must submit your request in writing to State of Franklin Healthcare Associates at the following address: Attn: Privacy Officer, 2528 Wesley Street, Suite 2, Johnson City, TN 37601. Unless otherwise revoked, this authorization will expire as indicated on page 1 or within one year from the time the form was signed.
  3. You may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain treatment, payment, enrollment or your eligibility for benefits. However, you may be required to complete this authorization form before receiving treatment if you have authorized your provider to disclose information about you to a third party. If you refuse to sign this authorization, and you have authorized your provider to disclose information about you to a third party, your provider has the right to decide not to treat you or accept you as a patient in their practice.
  4. Once the information about you leaves this office according to the terms of this authorization, this office has no control over how it will be used by the recipient. You need to be aware that at that point your information may no longer be protected by HIPAA. If the person or entity receiving this information is not a healthcare provider or health plan covered by federal privacy regulations, the information described above may be disclosed to other individuals or institutions and no longer protected by these regulations.
  5. You may inspect or copy the protected health information to be used or disclosed under this authorization. You do not have the right of access to the following protected health information: psychotherapy notes, information compiled for legal proceedings, laboratory results to which the Clinical Laboratory Improvement Act ("CLIA") prohibits access, or information held by certain research laboratories. In addition, our provider may deny access if the provider reasonably believes access could cause harm to you or another individual in some of these circumstances, an individual has a right to have the denial reviewed by a licensed health care professional designated by the covered entity who did not participate in the original decision to deny.
  6. If this office initiated this authorization, you must receive a copy of the signed authorization.
  7. Special Instructions for completing this authorization for the use and disclosure of Psychotherapy Notes. HIPAA provides special protections to certain medical records known as "Psychotherapy Notes." All Psychotherapy Notes recorded on any medium by a mental health professional (such as a psychologist or psychiatrist) must be kept by the author and filed separate from the rest of the client’s medical records to maintain a higher standard of protection. "Psychotherapy Notes" are defined under HIPAA as notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint or family counseling session and that are separate from the rest of the individual’s medical records. Excluded from the "Psychotherapy Notes" definition are the following: (a) medication prescription and monitoring, (b) counseling session start and stop times, (c) the modalities and frequencies of treatment furnished, (d) the results of clinical tests, and (e) any summary of: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. Except for limited circumstances set forth in HIPAA, in order for a medical provider to release "Psychotherapy Notes" to a third party, the client who is the subject of the Psychotherapy Notes must sign this authorization to specifically allow for the release of Psychotherapy Notes.
  8. You have a right to an accounting of the disclosures of your protected health information by the provider or its business associates. The maximum disclosure accounting period is the six years immediately preceding the accounting request. The provider is not required to provide an accounting for disclosures: (a) for treatment, payment, or health care operations; (b) to you or your personal representative; (c) for notification of or to persons involved in an individual’s health care or payment for health care, for disaster relief, or for facility directories; (d) pursuant to an authorization; (e) of a limited data set; (f) for national security or intelligence purposes; (g) to correctional institutions or law enforcement officials for certain purposes regarding inmates or individuals in lawful custody; or (h) incident to otherwise permitted or required uses or disclosures. Accounting for disclosures to health oversight agencies and law enforcement officials must be temporarily suspended on their written representation that an accounting would likely impede their activities.

Acknowledgement of Notice of Privacy Practices

If no, what other number (i.e. cell phone, private work number) may we try to reach you to leave a message?






Emergency Contact Number other than YOUR home phone number: (Please note, you are giving permission for this emergency contact to receive your personal health information if necessary.)




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 health information, i.e. lab results or billing issues, you can either leave or discuss the information with the following individual(s):

















ACCESS YOUR MEDICAL INFORMATION ONLINE, 24/7 ANYWHERE, ANYTIME!




Registration, Billing and Collection 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, American Express and Care Credit. In an effort to simplify the payment process, we provide a convenient, highly secure Credit/Debit/HSA card and Bank ACH payment program. You will be asked to provide a card-on-file (card/ACH-based) assurance at the time of service. After the insurance claim has been filed (if applicable), we will send you an electronic bill of your final financial responsibility. Your card-on-file will be charged for your out-of-pocket responsibility after the notice period and an electronic receipt will be emailed to you.

Please realize, however, that:

  • 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.
  • 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/guarantor.
  • Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. Any service not covered is the responsibility of the patient/guarantor.

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 payment arrangements.

By signing this financial policy acknowledgement of the financial responsibility is accepted. This 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.