Patient Information Packet | Columbus Children's Clinic

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Part A — Family & Patient Information

Mother's Information

Mother's Full Name *

Date of Birth

Marital Status

Employer

Work Telephone

Social Security No. (optional)

Father's / Second Parent's Information

Father's Full Name

Date of Birth

Marital Status

Employer

Work Telephone

Social Security No. (optional)

Contact & Address

Permanent Mailing Address *

Home / Residence Phone *

Cell Phone

Email Address *

Custody Status (if parents not living together or child not living with parents)

Total Household Members — Adults

Total Household Members — Children

No. of Smoking Household Members

Type of Dwelling

Patient Attending Day Care / School?

Patient-Child(ren)'s Information

List all children to be seen at this practice.

Child's Full Name *Date of Birth *SS No. (optional)Allergies (if any)

Emergency Alternative Contact

A relative or friend NOT living with you.

Contact Name *

Home Phone *

Cell / Other Phone

Part B — Insurance & Pharmacy Information

Primary Insurance

Insurance Company *

Policy Number

PCP / Group

Policy Holder's Name

Policy Holder DOB

Relationship to Patient

Secondary Insurance (if applicable)

Insurance Company

Policy Number

PCP / Group

Policy Holder's Name

Policy Holder DOB

Relationship to Patient

Pharmacy Information

Pharmacy Name

Address / Location

Pharmacy Phone

Part C — Practice Policies

Columbus Children's Clinic Key Operating Policies

Consent to Care/Treat plus To Bill & Collect: My signature on this Agreement signifies that I do hereby give permission for Dr. Shilpa J. Vernekar, dba Columbus Children's Clinic, LLC (CCC) &/or any of her support Clinical Staff, to care &/or treat my above-mentioned child(ren). I likewise authorize Dr. Vernekar or CCC to bill & collect from the above-named Insurance Co(s)., all the corresponding charges due. When any of the service charges are not paid by the said Insurance Co(s)., I agree to ultimately be the one responsible to fully pay for it.

1.0 Co-Payments & Service Charges

All Co-Payments & Service Charges not covered by Patient's insurance are due at the time of service. "Previous Unpaid Balance", "Co-Pays", "Deductibles" &/or "Self-Pay" charges are to be paid by the Patient's parent/guardian while checking in. Misrepresentation, non-payment of long outstanding accounts, non-compliance, plus absence of mutual trust & confidence shall be enough grounds for terminating the existing "Patient-Physician" relationship.

2.0 Insurance & Address Changes

Patient's parents/guardians are required to promptly inform us when there are changes to their mailing address, contact phone numbers, insurance carrier, co-pays/deductibles &/or insurance benefits. When parents/guardians fail to give us their child's correct insurance coverage information promptly, and it was the main cause of service charges' reimbursement claim's denial or non-payment, the unpaid obligation shall be borne and paid by the parent(s).

3.0 Appointments

Except for sick patients needing urgent care, all Doctor's visits are "By Appointment" only. Parents/guardians are required to call to make changes &/or cancellations at least four (4) hours before, or it will be considered a "NO SHOW". A "No-Show" fee of up to $20.00 will be assessed per incident. Two (2) consecutive or a total of four (4) "NO SHOWs" shall mean permanent expulsion from Columbus Children's Clinic (CCC).

4.0 Insurance Card & Photo ID

It is always the Patient's parents/guardian's primary responsibility to remember and keep their child(ren)'s appointment(s) and make sure that their child(ren)'s insurance coverage is/are active or current. Parents/Guardians are also required to bring their current government-issued picture ID and their child(ren)'s valid/current insurance cards for presentation at every visit.

5.0 Priority & Wait Times

Priority will always be given to those with scheduled appointments & who come on time. Patients who come in later than 15 minutes from their scheduled appointment time will be pushed back. Those who are 'late' by 30 minutes or more may be rescheduled.

6.0 Records & Forms Fees

A nominal reproduction &/or handling service fee will be assessed for each request for a Patient's Medical Records, Lost Prescription, Head Start form, Sports Physical form, FMLA, Disability/Other Insurance Reimbursement forms, Adoption forms, or other Administrative forms. Medical Records = at least 5 working days after receipt of written Authorization. All other forms = at least 1 day after actual receipt of request.

7.0 Not Allowed in Clinic

The following are NOT allowed: deadly weapons, smoking, food &/or drinks (except baby's formula), using or talking on your mobile phone while the Care Provider is with you inside the Exam Room, cursing or shouting, horse playing/arguing, and throwing dirty diapers inside trash cans &/or littering inside the clinic or its vicinity.

I have read, understood, and accept all of the above operating policies. *

Part D — Patient Medical History

Patient Being Seen

Patient Name *

Date of Birth *

Sex

Form Completed By

Relation to Patient

Patient's Birth History

Birth Weight

Born at Term?

If Early, No. of Weeks

Did Mother have any illness or problems during pregnancy? Explain:

Did baby have any problems right after birth? Explain:

Did baby go home with Mother from the hospital?

If No, explain:

Family Medical History

Did any family members (Mother, Father, Siblings, Paternal or Maternal Grand Parents) have any of the following? If Yes, please note who.

Condition	Yes / No	If Yes, Who
ADHD	Yes No
Anemia	Yes No
Asthma	Yes No
Alcohol Abuse	Yes No
Bleeding Problem	Yes No
Diabetes (Before 50 y.o.)	Yes No
Deafness	Yes No
Drug Abuse	Yes No
Epilepsy or Convulsions	Yes No
Cancer (Any form)	Yes No
Unhealthy Weight / Obesity	Yes No
Smoking	Yes No
Heart Disease (Before 50 y.o.)	Yes No
High Blood Pressure (Before 50 y.o.)	Yes No
High Cholesterol	Yes No
Immunity Problem / AIDS	Yes No
Kidney Disease	Yes No
Liver Disease	Yes No
Mental Illness	Yes No
Nasal Allergies	Yes No
Tuberculosis	Yes No
Thyroid / Other Endocrine Problem	Yes No

Additional relevant family medical history:

Patient's Past Medical History

Condition / History	Yes / No	Explain (if Yes)
Chicken Pox	Yes No
Frequent Ear Infections	Yes No
Problems with Ears or Hearing	Yes No
Problems with Eyes or Vision	Yes No
Asthma, Bronchitis, Bronchiolitis or Pneumonia	Yes No
Nasal Allergies	Yes No
Anemia or Bleeding Problem	Yes No
Heart Problem or Heart Murmur	Yes No
Blood Transfusion	Yes No
Bladder or Kidney Infection	Yes No
Bed Wetting (after 5 y.o.)	Yes No
Frequent Abdominal Pain	Yes No
Chronic Constipation Requiring Doctor's Visit	Yes No
Frequent Headaches	Yes No
Convulsions or Other Neurologic Problem	Yes No
Diabetes	Yes No
Thyroid or Other Endocrine Problem	Yes No
Chronic or Recurrent Skin Problem (Eczema, Acne, etc.)	Yes No
Use of Alcohol or Illegal Drugs	Yes No
Liver Problem	Yes No
For Girls: Has she started her menstrual periods?	Yes No N/A
For Girls: Are there problems with her periods?	Yes No N/A

Any other significant medical problem(s) — please specify:

Part E — HIPAA Authorization for Use & Disclosure of PHI

Authorization for Use & Disclosure of Patient's Protected Health Information

By submitting this form, I authorize Columbus Children's Clinic c/o Dr. Shilpa Vernekar to use and disclose my child's Protected Health Information (PHI) for reasons other than treatment, payment or health care operations, only for the following specific purpose(s) as I have indicated below:

Return to School / Nursery Excuses Return to Work Excuses Calling Home for Laboratory Results Calling Home for Appointment Reminders

Other purposes (please specify):

This authorization will expire on:

6 months from signing Automatically renews unless I say otherwise

Columbus Children's Clinic will not in any way receive payment or other remuneration from a third party in exchange for using or disclosing my child's PHI. I do not have to sign this authorization in order for my child to receive treatment. I have the right to refuse to sign this authorization. I have the right to revoke this authorization in writing at any time by submitting written revocation to the Privacy Officer at 1546 10th Ave. Suite A, Columbus, GA 31901.

Final Certification & Signature

By typing my name below and submitting this form, I certify that all information provided is true and accurate. I have read and accept the service/payment agreement, operating policies, and HIPAA authorization above. This constitutes my electronic signature.

Patient's Name *

Patient's Date of Birth *

Parent / Legal Guardian Printed Name *

Electronic Signature (type full name) *

Relationship to Patient *

Date Signed *

Do you consider your child to be in good health?	Yes No
Does your child have any serious illness or medical condition?	Yes No
Has your child had any serious injuries or accidents?	Yes No
Has your child had any surgery?	Yes No
Has your child ever been hospitalized?	Yes No
Is your child allergic to any medicines / drugs?	Yes No