New Patient Registration
Patient Information
Patient Full Name
Patient DOB
Sex
M
F
Other
Name of Parent/Guardian where patient lives
Address where patient lives
City
State
Zip
Mobile Phone
Emergency Phone
Email
Is there a Second Parent/Guardian?
Yes
No
Second Parent/Guardian Name
Phone
Patient Race
Select
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other
Prefer Not to Answer
Ethnicity
Hispanic
Non-Hispanic
Preferred Language
Insurance Information
Does the Patient have Healthcare Insurance Coverage?
Yes
No
Insurance Policyholder Name
Policyholder DOB
Relationship to Patient
Mother
Father
Self/Medicaid
Other
Insurance Company
Policy ID/Account No.
Policy Group No.
Copay Amount
Please upload an image of your insurance card (front and back)
To select multiple files, hold down the CTRL or SHIFT key while selecting.
Does the Patient have Secondary Healthcare Insurance Coverage?
Yes
No
Secondary Insurance Policyholder Name
Policyholder DOB
Relationship to Patient
Mother
Father
Self/Medicaid
Other
Insurance Company
Policy ID/Account No.
Policy Group No.
Copay Amount
Please upload an image of your insurance card (front and back)
To select multiple files, hold down the CTRL or SHIFT key while selecting.
Appointment Information
Please let us know if:
You have an appointment already scheduled with us for the patient above
You would like us to call you to schedule an appointment
You would like to add this patient to our system but do not need an appointment yet
Receipt of Notice of Privacy Practices
I acknowledge that I have reviewed the
Notice of Privacy Practices for Elemental Pediatrics, LLC
and have been offered a printed or electronic copy if desired.
Patient Name
Patient Date of Birth
Name of Parent/Guardian
Relationship to Patient
Universal Authorization Waiver
For this document, “we,” “us,” “our,” and “I” refer to the patient, parent(s), guardian(s) (in singular and in plural as applicable) and “office” refers to Elemental Pediatrics LLC and its doctors, providers, employees, and authorized agents. With our signature, we grant consent to the office for the following permissions. We may revoke consent for any or all permissions in writing in a separate document, although revocation of some permissions may result in the office being unable to provide care/services to us. These permissions shall remain in effect until revoked by either party.
Permission to Contact:
We give consent for the office to contact us by any method for which we have given our contact information and/or which the office discovers by other legal methods such as from insurance companies, healthcare providers, other individuals, etc. Examples include email, text/SMS message, portal message, postal mail, fax, and phone. We understand that it is our responsibility to keep the office informed of changes to our contact information. The office HIGHLY recommends that we use the portal to allow all communications to be recorded in the patient chart. All such contact by the office will follow the privacy policy and Notice of Privacy Practices. The office will use our preferred method of contact whenever possible but may use other methods if necessary. Appointment reminders sent to us by any of the methods are strictly a courtesy and failure of such notices does not relieve us of our responsibility to attend the appointment on time. Specifically related to SMS messaging, replying STOP will end that form of communication.
Why?
It is important for the office to be able to reach us.
Permission to submit insurance:
If the patient is covered by an insurance plan with which the office has a contract, the office must adhere to the terms of that contract. The insurance company information may be provided by us or may be discovered by the office from other sources such as insurance registries, hospitals, etc. As a courtesy, the office will file the insurance claim for us for contracted plans and we grant consent for all required information to be provided for claim processing. It is our responsibility to provide the insurance company with any requested information, including following any procedures for authorization. We assign all benefits and payments from the insurance company to be paid to the office. We accept all responsibility for any services not covered by the insurance which are legally billable to us or when insurance in inactive or invalid. We agree to make prompt payment for any amounts due, generally understood to be within 30 days of being billed. Payment delays may incur additional charges, and we accept all responsibility for any fees related to collection efforts. In the event of financial hardship, we will contact the office to discuss payment terms. We give permission for the office to file an appeal on our behalf if needed and accept responsibility for appeals when our participation in such is necessary.
Why?
Our insurance company requires the office to do this.
Permission to share clinical information:
The office participates in Clinical Document Exchange. This means that our records will be shared automatically ONLY for treatment purposes to and from legally certified agencies which request them or from which the office requests them. This includes vaccine information shared to and from the ShowMeVax state immunization registry and prescription information shared to and from SureScripts and the Missouri Prescription Drug Monitoring program.
Why?
It is important for the office and other healthcare providers to have full medical information available to provide the best care.
Permission for AI assistance:
The office may use Artificial Intelligence solutions to collect information during a visit, on phone calls or other interactions, and in compiling medical history and plans. The office will never use it without human interaction and guidance and will only use it in ways which protect our privacy.
Why?
This technology allows visit information capture and other assistance to facilitate our care.
Permission to share anonymous data for research:
The office participates in research with agencies such as the American Academy of Pediatrics and others. Data regarding health trends such as blood pressure, medication side effects, etc. can be searched from our records but IN NO WAY will that be linked to us. Any research that could be linked to us will require informed consent separate from this document.
Why?
It is important to gather large amounts of data to find health trends and risks across the population.
Permission for pictures:
We grant permission for digital pictures for patient care (for example, of a rash or lesion) to be stored in the patient chart for medical documentation and to be considered a part of the medical record. If we provide a picture to the office (such as a school picture, holiday card, or one drawn/created by us), we grant permission for it to be displayed in the office or online (website or social media), even if it includes a name or other information that would ordinarily be considered protected health information. The office will not and may not add any such protected health information to our picture.
Why?
Pictures for patient care are very helpful and other pictures are appreciated.
Patient Name
Patient Date of Birth
Name of Parent/Guardian
Relationship to Patient