Gender*
Male   Female

Allergies to any Medications?*
Yes   No

Gender
Male   Female

Gender
Male   Female

Do you have Healthcare Insurance? *
Yes     No

Parent/Guardian 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.

 

Gender*
Male   Female

Were there any complications with pregnancy?*
No   Yes

Were there any complications with childbirth?*
No   Yes

Was this child born prematurely?*
No   Yes

Did this child require care in the newborn ICU?*
No   Yes

Did this child fail the newborn hearing screening?*
No   Yes

Has this child had any developmental delay?*
No   Yes

Has this child had any problems with growth?*
No   Yes

Has this child been hospitalized (excluding birth)?*
No   Yes

Has this child ever had surgery?*
No   Yes

Does this child have asthma or any lung disease?*
No   Yes

Does this child have any history of seizures?*
No   Yes

Does this child have any history of allergies?*
No   Yes

Does this child have a history of ADD/ADHD?*
No   Yes

Does this child have any other medical problems?*
No   Yes

Is the child ALLERGIC to any medications?*
Yes   No

Is the child CURRENTLY taking any medication (prescription or non-prescription)?*
Yes   No

Is there any family history of the following?

Hearing loss?*
No   Yes

Anesthesia complications?*
No   Yes

Bleeding abnormalities?*
No   Yes

Developmental problems?*
No   Yes

Is this child in daycare?*
No   Yes

Is this child in school?*
No   Yes

Is this child living with a smoker?*
No   Yes

Are there any household pets?*
No   Yes

Ear Infections*
Yes   No   

Hearing Problems*
Yes   No   

Patient/Legal Representative Name

The HIPAA Privacy Rule gives individuals the right to direct how and where their healthcare provider communicates with them, such as sending correspondence to the individual’s office instead of the individual’s home. We invite you to share with us your preferred place and manner of communication. You may update or change this information at any time; please do so in writing.

I prefer to be contacted in the following manner (check all that apply):

OK to leave message with detailed information
Leave message with call-back number only

OK to leave message with detailed information
Leave message with call-back number only

OK to leave message with detailed information
Leave message with call-back number only

OK to mail to my home address
OK to mail to my work/office address

We respect your right to indicate who you prefer that we involve in your treatment or payment decisions and/or who we share your information with, including information about your general medical condition and diagnosis (such as treatment and payment options), access to medical records (PHI), prescription pick-up and scheduling appointments. Please note, however, that we may share your information as set forth in our Notice of Privacy Practices to other persons as needed for your care or treatment or the payment of services we have provided. Please update this information promptly if your preferences change.

Please indicate the person(s) you prefer we share your information with below:

Parent/Guardian 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.

 

Assignment of Benefits and Authorization to Release Medical Information. I hereby certify that the insurance information I have provided is accurate, complete and current and that I have no other insurance coverage. I assign my right to receive payment of authorized benefits under Medicare, Medicaid, and/or any of my insurance carriers to the provider or supplier of any services furnished to me by that provider or supplier. I authorize Privia to file an appeal on my behalf for any denial of payment and/or adverse benefit determination related to services and care provided. If my health insurance plan does not pay Privia directly, I agree to forward to Privia all health insurance payments which I receive for the services rendered by Privia and its health care providers. I authorize Privia or any holder of medical information about me or the patient named below to release to my health insurance plan such information needed to determine these benefits or the benefits payable for related services. I understand that if my insurance plan does not participate in the Privia network, or if I am a self-pay patient, this assignment of benefits may not apply.

Guarantee of Payment & Pre-Certification. In consideration of the services provided by Privia and its providers, I agree that I am responsible for all charges for services provided not covered by my health insurance plan or for which I am responsible for payment under my health insurance plan. I agree to pay all charges not covered by my health insurance plan or for which I am responsible for payment under my health insurance plan. I further agree that, to the extent permitted by law, I will reimburse Privia for all costs, expenses and attorney’s fees incurred by Privia to collect those charges.

If my insurance has a pre-certification or authorization requirement, I understand that it is my responsibility to obtain authorization for services rendered according to the plan’s provisions. I understand that my failure to do so may result in reduction or denial of benefit payments and that I will be responsible for all balances due.

Consent to Treatment. As a Privia patient, I voluntarily consent to the rendering of such care and treatment as Privia providers and personnel, in their professional judgment, deem necessary for my health and well-being.

If I request or initiate a telehealth visit (a “virtual visit’), I hereby consent to participate in such telehealth visit and its recording and I understand I may terminate such visit at any time.

My consent shall cover medical examinations and diagnostic testing (including testing for sexually transmitted infections and/or HIV, if separate consent is not required by law), including, but not limited to, minor surgical procedures (including suturing), cast application/removals and vaccine administration. My consent shall also cover the carrying out of the orders of my treating provider by care center staff. I acknowledge that neither my Privia provider nor any care center staff have made any guarantee or promise as to the results that may be obtained.

Consent to Call, Email & Text. I understand and agree that Privia may contact me using automated calls, emails and/or text messaging sent to my landline and/or mobile device. These communications may notify me of preventative care, test results, treatment recommendations, outstanding balances, or any other communications from Privia. I understand that I may opt-out of receiving such communications from Privia and its partners by notifying Privia at privacy@priviahealth.com, by informing my provider’s staff, or by visiting “My Profile” on my Privia Patient Portal.

HIPAA. I understand that Privia’s Privacy Notice is available at priviahealth.com/hipaa-privacy-notice/ and my care center’s website, and that I may request a paper copy at my care center’s reception desk.
 

---

I hereby acknowledge that I have received Privia’s Financial Policy and Privia’s Notice of Privacy Practices. I agree to the terms of Privia’s Financial Policy, the sharing of my information via HIE,* and consent to my treatment by Privia providers. This form and my assignment of benefits applies and extends to subsequent visits and appointments with Privia providers.

Parent/Guardian 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.

 

*Note: If you do not want to participate in Health Information Exchange (HIE), it is your responsibility to follow the instructions outlined on the Privia HIE Opt-Out Request Form and/or contact the HIE directly.

---

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.