M.T. Curry Inc

NEW PATIENT REGISTRATION

Patient Information

First Name * Middle Name * Last Name * Date of Birth * Was the patient premature? * If YES, how many weeks early were they? SSN Sex * Race * Ethnicity * Preferred Language *

Demographic Information

Street Address * City * State * Zip Code * Home Phone Cell Phone * Work Phone Email * Preferred Method of Contact * School * Preferred Pharmacy * Pharmacy Address * Pharmacy Phone *

Guardian Information

First Name * Last Name * Relationship to Patient * SSN * Date of Birth * Address Home Phone Cell Phone * Email * Employer * Work Phone *

Please fill out the following section with the second guardian's information

First Name * Last Name * Relationship to Patient * SSN * Date of Birth * Address * Home Phone Cell Phone * Email * Employer * Work Phone * Is there a custody agreement in place for the patient? * Emergency Contact * Emergency Contact Name Date of Birth Relationship to Patient Primary Phone Would you like to give anyone else consent to accompany the patient to their appointments? *

Insurance Information

Please email a copy of the FRONT & BACK of the patient's insurance card to currypeds@myupdox.com.

Primary Insurance Name * Member ID * Group # * Policy Type * Provider Services Phone Number * Does your insurance require you to go to a specific lab for bloodwork? * If YES, where? *

Fill out the following section using the subscribers information for the primary insurance.

Name * Date of Birth * SSN * Secondary Insurance Name Member ID Group # Provider Services Phone Number

Fill out the following section using the subscribers information for the secondary insurance.

Name Date of Birth SSN

Consent to Treatment

This consent provides us with your permission to perform necessary medical examinations, testing and treatment on your child. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your child's physician about the purpose, potential risks and benefits of any test, lab or immunization ordered for your child. By signing below, you certify that you have read and fully understand the above statements and consent fully and voluntarily to its contents.

I Agree * Signature * Today's Date *

Consent to Leave Messages

In compliance with HIPPA laws and to better protect your family?s privacy, M. T. Curry Pediatrics needs consent to leave voicemails and send secure text messages regarding your child/children?s test results, appointments, referrals, or billing/insurance information. By signing at the end of this section you give M. T. Curry Pediatrics permission to send or leave detailed messages at any the phone numbers that you have listed on the Patient Registration. If there are any numbers that you would not like for us to leave a message on please let our staff know and they will update your contact information.

I Agree * Signature * Today's Date *

OFFICE & FINANCIAL POLICIES

Financial Obligation

All copays, deductibles and non-covered services as determined by the patient's insurance plan are the responsibility of the guarantor(s). Copays are due at the time of check-in, regardless of who accompanies the patient to their appointment. If you do not have the copay or have not come prepared to pay past due balances, the patient?s appointment may be rescheduled for a later time (Except in the case of a medical emergency) so that the financial obligation can be met. If the insurance plan requires a PCP (Primary Care Physician), we ask that the patient?s physician at M. T. Curry Pediatrics is designated on their insurance. By checking the box below and providing your e-signature you confirm that you understand and agree to these terms.

I Agree * Signature * Today's Date *

Payment Verification

Please bring the patient?s current insurance information & credit card/ debit/ HSA/ flex spending card with you to every visit. If your insurance changes, please notify us before the appointment so we can make the appropriate changes to help you receive your insurance benefits. M. T. Curry INC will not retroactively bill any claims for new or existing insurance policies that were not presented prior to services being rendered. We attempt to verify your insurance two (2) business days prior to your visit, and again on the morning of. Verification of coverage is not a guarantee of insurance payment. If we are unable to confirm active insurance coverage by the scheduled appointment time, you will have two options: 1) Pay for the visit out of pocket. 2) Reschedule for another day when you have had an opportunity to contact your insurance. For same day appointments, we will check eligibility when the appointment is made. When a balance is due you will receive a statement via postmarked mail &/or e-mail. If the balance is not paid within 30 days, a past due statement will be sent as a courtesy. If the balance is not paid within 60 days, the account(s) will be forwarded to collections with interest. Guarantors will be responsible for payment of all attorney?s fees, collection agency fees or any other fees associated with collecting any outstanding balance to include outstanding principal balances, interest, late fees, court costs and filing fees, postage and handling fees, or courier fees. We accept cash, checks, MasterCard, VISA and Discover Card. There is a fee for any returned checks. By checking the box below and providing your e-signature you confirm that you understand and agree to these terms.

I Agree * Signature * Today's Date *

Late Arrivals & Missed Appointments

We ask you to arrive 15 minutes early to your appointment for check in and triage. If you arrive more than 15 minutes after your check in time, you may need to be rescheduled. We confirm appointments 2 business days and 24 hours in advance and require a 24-hour cancellation notice if you are unable to keep your appointment. Missed appointments or appointments that are cancelled without 24 hours? notice will result in a $25.00 No Show fee. If a family has a pattern of repeated missed appointments, late arrivals or last-minute cancellations, they may be asked to leave the practice. By checking the box below and providing your e-signature you confirm that you understand and agree to these terms.

I Agree * Signature * Today's Date *

HIPAA Notice of Privacy Practices: As required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. ?Protected health information? is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by our organization, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the organization, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for equipment or supplies coverage may require that your relevant protected health information be disclosed to the health plan to obtain approval for coverage.

Healthcare Operations: We may use or disclose, as?needed, your protected health information in order to support the business activities of our organization. These activities include, but are not limited to, quality assessment activities, employee review activities, accreditation activities, and conducting or arranging for other business activities. For example, we may disclose your protected health information to accrediting agencies as part of an accreditation survey. We may also call you by name while you are at our facility. We may use or disclose your protected health information, as necessary, to contact you to check the status of your equipment.

We may use or disclose your protected health information in the following situations without your authorization: as Required By Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Criminal Activity, Inmates, Military Activity, National Security, and Workers? Compensation. Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures Will Be Made Only with Your Consent, Authorization or Opportunity to Object, unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or this organization has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights: Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Our organization is not required to agree to a restriction that you may request. If our organization believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, e.g., electronically.

You may have the right to have our organization amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information, if you have any questions concerning or objections to this form, please ask to speak with our Vice President in person or by phone at 757-547-5851.

Associated companies with whom we may do business, such as an answering service or delivery service, are given only enough information to provide the necessary service to you. No medical information is provided.

We welcome your comments: Please feel free to call us if you have any questions about how we protect your privacy. Our goal is always to provide you with the highest quality services.

I understand the Notice of Privacy Practices information made available to me regarding HIPAA. I understand that I have the right to ask for a complete copy of this information for evaluation at any time. * Signature * Today's Date *

Help us make your first appointment!

When was the patient's last Well Child Check (Physical Exam)? * Please list any preexisting conditions: * Please list any prescription medications the patient has ever taken: * How did you hear about us? *

Please bring a valid ID or Passport, Insurance Card(s), Prescription Bottles and any Medical Records you have to the first appointment. Families without valid form of ID will not receive any services.

Please return to currypeds.com > Home to complete the Medical Records Release Form for your child.