Privia Medical Group logo

MINOR REGISTRATION FORM

Maryland ENT logo

2415 Musgrove Road, Suite 203
Silver Spring, Maryland 20904
(301) 989-2300
 
 
Minor Patient Information
Gender*
 
Allergies to any Medications?*
 
Parent #1 Information
Gender
 
Parent #2 Information
Gender
 
Insurance Information
Do you have Healthcare Insurance? *
Authorization

I hereby authorize Maryland ENT Associates to apply for benefits on my behalf for services rendered to my minor child and request that payment be made by my insurance company and that payments be sent directly to Maryland ENT Associates. I understand that it is the policy of Maryland ENT Associates to only bill my insurance company if they participate with that company, and if they do not, it will be my responsibility to bill my insurance company for reimbursement of my expenses. I further authorize Maryland ENT Associates to release necessary information to my insurance company, or to the Insurance Commissioner of MD as necessary to obtain payment for my services.

I understand that this in no way relieves me of my primary responsibility to pay for services rendered to my minor child, and if my account is turned over to an attorney for collection, I agree to pay any collection and reasonable legal fees (40% is deemed reasonable) court costs, and other expenses incurred as a result of said collection, all actions having a venue of Montgomery County, MD, other venues notwithstanding. Further, I understand that there is a $25.00 fee for returned checks and $50.00 for missed appointments.

I certify that the information I have reported with regard to my insurance coverage is correct and I authorize the release of any information relating to any claim for benefits, in order to process any claim for benefits. Furthermore, I permit a copy of this authorization to be used in place of the original. I may revoke this authorization at any time in writing.

I understand that the information contained on this form will be used to process my billing and/or insurance claims for service received in this office. It is important to be sure that this information is correct prior to receiving care to prevent problems for the patient in the future.

Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 

 

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PEDIATRIC AND ADOLESCENT MEDICAL HISTORY

 
Minor Patient Information
Demographics
Gender*
 
Past History
Were there any complications with pregnancy?*
 
Were there any complications with childbirth?*
 
Was this child born prematurely?*
 
Did this child require care in the newborn ICU?*
 
Did this child fail the newborn hearing screening?*
 
Has this child had any developmental delay?*
 
Has this child had any problems with growth?*
 
Has this child been hospitalized (excluding birth)?*
 
Has this child ever had surgery?*
 
Does this child have asthma or any lung disease?*
 
Does this child have any history of seizures?*
 
Does this child have any history of allergies?*
 
Does this child have a history of ADD/ADHD?*
 
Does this child have any other medical problems?*
 
Is the child ALLERGIC to any medications?*
 
Is the child CURRENTLY taking any medication (prescription or non-prescription)?*
 
Family History
Is there any family history of the following?
Hearing loss?*
 
Anesthesia complications?*
 
Bleeding abnormalities?*
 
Developmental problems?*
 
Social History
Is this child in daycare?*
 
Is this child in school?*
 
Is this child living with a smoker?*
 
Are there any household pets?*
 
Review of Systems
Ear Infections*
 
Hearing Problems*
 
Drainage from Ears*
 
Speech Problems*
 
Nasal Congestion*
 
Runny Nose*
 
Cough*
 
Snoring*
 
Mouth Breathing*
 
Noisy Breathing*
 
Bedwetting*
 
Feeding Difficulties*
 

 

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ACKNOWLEDGEMENT of RECEIPT

 
of Notice of Privacy Practices

Click here to view our Notice of Privacy Practices.

I have received the Notice of Privacy Practices from Maryland ENT Associates, effective date 9/23/2013

Patient/Legal Representative Name
Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
Disclosure to Family/Friends

 
NOTE: When finished, please click the Submit Registration button below to send your form securely to our office. If you need to print a copy, please do so before clicking Submit.

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