Patient Registration

First name

Last name

Nickname

Date of birth

Sex
Male Female Other

Preferred contact phone

Accepts text messages
Yes No

Email

Do you allow Northpointe Pediatrics to electronically obtain medical/pharmaceutical records from other facilities?
Yes
No

Race (check all that apply)
African American/Black
Caucasian/White
Asian
American Indian/Alaska Native
Native Hawaiian/Other Pacific Islander
Refuse to respond

Ethnicity (select one)
Hispanic/Lastino
Non Hispanic/Non Latino
Refuse to respond

Legal Parent Name

Date of Birth

Phone

Address

City

State

Zip

Employer

Social Security No.

Add another parent?

Which parent does the child reside with?

or both parents

Other person(s) authorized to seek care for your child besides parents

Does the child have healthcare insurance?
Yes
No

In the case of an emergency, in which a parent/legal guardian cannot be reached, we may need to call someone on your child’s behalf. Please list below the name of someone we have your permission to contact if necessary:

Emergency Contact
Name of person NOT LIVING WITH CHILD

Relationship to child

Financial Policy

We are committed to providing your child/children with the best possible care. If you have insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our payment policy.

Payments, including co-pays, are due at the time services are rendered, unless payment arrangements have been approved by our billing department. There will be a $5.00 charge added to your account for billing costs if payment is not made at the time of service. We accept cash, check, MC, Visa, Discover and American Express cards. Returned checks and balances older than 30 days will be subject to additional fees.

While filing of participating insurance claims is a courtesy that we extend to all our patients, all charges are ultimately your responsibility on the day services are rendered. Please be aware that insurance companies arbitrarily select certain services they will not cover under your insurance plan. We emphasize then, as health care providers, our relationship is with YOU, and not your insurance company.

We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact our billing department promptly for assistance in management of your account. All past due accounts over 90 days will be handled by Transworld Systems Inc.

It is the policy of Northpointe Pediatrics, P.C. that the parent bringing the child in for care is responsible for payment of co-payments and those services not covered by your insurance plan.

We report all evening, weekend and holiday visits to your insurance carrier. This code may or may not be covered.

You may cancel an appointment with no charge any time before 7pm on the day preceding your appointment. Same day cancellations or a “no show” for your scheduled appointment will result in a $25 charge for a sick visit and $50 charge for a well child exam.

If you have any questions or concerns pertaining to our financial policy, please do not hesitate to ask us. We are here to help you.

Authorization for Treatment and Release of Information

I authorize Northpointe Pediatrics, P.C. to evaluate and treat my child/children and to release to our insurance company any information acquired in the course of my child’s examination or treatment, and to receive all payments for such examination or treatment. Northpointe Pediatrics, P.C. has my permission to release any diagnostic studies, report, etc. to a specialist involved in caring for my child.

I understand that a parent/legal guardian must be present for my child’s well visits. If this is not possible and someone else must bring my child, a written authorization with the parent/legal guardian’s contact information will be provided and all insurance co-payments will be made.

All information that I given is correct to the best of my knowledge. I understand that it will be held in the strictest of confidence, and it is my responsibility to inform this office of any changes in my child’s medical status. I understand and agree to the terms of the above financial policy.

I assign directly to Northpointe Pediatrics, P.C. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I acknowledge that I have been offered a copy of Northpointe Pediatrics, P.C. “Notice of Privacy Practices”

I authorize the use of this signature on all my insurance submissions whether manual or electronic.

Signature of Parent or Legal Guardian – 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.

Date

LuxSci helps ensure HIPAA-compliance for email and web services.