M.T. Curry Inc - Publicforms

Available Forms

12 Month Wellness Exam 12 Month Wellness Exam Spanish 18 Month Wellness Exam 18 Month Wellness Exam Spanish 24 Month Wellness Exam 24 Month Wellness Exam Spanish 3-21 Year Wellness Exam 3-21 Year Wellness Exam Spanish ACT 12 years and older ACT 12 years and older Spanish ACT 4 to 11 years ACT 4 to 11 years Spanish ADHD Agreement ADHD Agreement Spanish Adult ADHD Self-Report Scale Adult ADHD Self-Report Scale Spanish Conner's Pediatric Conner's Pediatric Spanish COVID-19 Screening English COVID-19 Screening Spanish 2 Family Medical History Family Medical History Spanish Flu Quest 2020 Flu Quest 2020 Spanish HIPAA 18yr HIPAA 18yr Spanish Interview & Lunch Rep COVID-19 Screening New Patient Registration New Patient Registration Spanish Newborn Insurance Waiver Newborn Insurance Waiver Spanish PHQ-9 and GAD (Patient Health Questionnaire and General Anxiety Disorder) PHQ-9 (Patient Health Questionnaire) PHQ-9 (Patient Health Questionnaire) Spanish Records Request Personal Use Records Request Personal Use Spanish Records Request Prior Doctor Records Request Prior Doctor Spanish Self Pay Waiver Self Pay Waiver Spanish Telehealth Agreement Update Demographics Returned Mail Vanderbilt - Parent Well Child Waiver Well Child Waiver Spanish

HIPAA 18yr

UPDATE DEMOGRAPHICS & CONSENT FORM

Dear Patient, When you turn 18, seeking medical care is a new responsibility. Once you become a legal adult, your parents or legal guardians are no longer considered your legal representatives. Under state law and federal HIPAA regulations, you can consent to your own medical care and control your own medical records and information. While we do encourage you to continue to discuss any health problems or concerns with your parents or legal guardians and to continue to seek their advice, with certain limited exceptions, we can no longer share any medical information about you with your parents, or anyone else, without your authorization. This means that you are responsible for your medical care and will have to call for your own appointments as needed.

THINGS TO KNOW

Under the Federal Health Information Portability and Accountability Act (HIPAA), access to your medical records and any discussion about your health limited to you and those you authorize. If you wish for your parents or legal guardians to discuss your health on your behalf, you must provide written HIPAA authorization. This form is called an Authorization to Use & Disclose Health Information form and is available for you below. M. T. Curry Pediatrics will continue to provide medical care for you until you reach 22 years of age. At that time, we can help you to make a smooth transition from pediatric care to Adult medicine. When calling for an appointment, you will need to let the receptionist know why you need to see the doctor (providing the most honest description of why you need to be seen so that appropriate time is scheduled), and when you need the appointment. Your parents may come to the appointment with you, but you will need to check in and sign any required paperwork yourself. Some of the forms you may be asked to fill out and sign are used to update your contact information, inform you of your financial responsibility and to consent to medical your treatment. You have the right to be informed of your medical care and treatment. You also have the right to refuse medical treatment, if you wish.

REQUIRED FORMS

Update Demographics & Consent Form: This form is needed for us to update your contact information so that we may reach you directly & gives us consent to treat you as a patient. Authorization to Use & Disclose Health Information: This form needs to be filled out only if you want to give your parents or any other individual access to your medical records. If we do not have the authorization, M. T. Curry Pediatrics WILL NOT be able to give any of your medical information out. Financial & Office Policies: This form outlines our practice & financial policies. By signing this form, you acknowledge that you are responsible for keeping your appointments and for any payment that needs to be made to our office.

Patient Information

First Name *

Patient First Name

Middle Name *

Patient Middle Name (Type N/A) if no Middle Name

Last Name *

Patient Last Name

Date of Birth *

SSN *

Sex *

Male

Female

Race *

Ethnicity *

Preferred Language *

Demographic Information

Street Address *

City *

State *

Zip Code *

Home Phone

Cell Phone *

Work Phone

Email *

Preferred Method of Contact *

School *

If the patient is not yet in school, type "N/A"

Preferred Pharmacy *

Pharmacy Address *

Pharmacy Phone *

CONSENT TO USE & DISCLOSE HEALTH INFORMATION

This office is required by Federal Regulations to inform our patients to the use of your health information accordance to Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that as part of my health care, M. T. Curry Pediatrics originates and maintains paper and/or electronic records describing my health history, symptoms, examinations, test results, diagnosis, treatments, and any plans for future care or treatment. I understand that this authorization will remain in effect until revoked in writing.

I understand that this is information serves as: A basis for planning my care and treatment, A means of communication among health professionals who contribute to my care, A source of information for applying my diagnosis and treatments information to my bill, A means by which a third-party can verify the services billed to me took place.

I understand and have been provided access to a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. This notice is located on our website www.currypeds.com and in all waiting areas in plain view.

I understand that I have the following rights and privileges: The right to review the Notice of Privacy Practices prior to signing this consent, allowing treatment, or making payment for services rendered and the right to a paper copy of the Notice of Privacy Practices. The right to object to the use of my health information for directory purposes. The right to request confidential communications. The right to inspect and copy. The right to amend or supplement The right to an accounting of disclosures.

I authorize M. T. Curry Pediatrics & it?s staff to discuss my medical information as follows, with the individuals indicated below.

Check all that apply *

Appointment Dates & Times

Financial & Billing Information

Treatment Plans or Referral Information (Medication &/or Therapy Information)

Laboratory Results

Confidential Information (Pregnancy Testing/STI Testing)

I do not wish to share any of my information

Please select all categories that you would allow to be shared with the listed parties.

First Name *

Type N/A if this does not apply

Last Name *

Type N/A if this does not apply

Date of Birth *

Enter Today's Date if this does not apply

Relationship to Patient *

Mother, Father, Legal Guardian, Foster Parent, etc. <br/><br/>Type N/A if this does not apply

First Name *

Type "N/A" if this does not apply

Last Name *

Type "N/A" if this does not apply

Date of Birth *

Type Today's Date if this does not apply

Relationship to Patient *

Mother, Father, Legal Guardian, Foster Parent, etc. <br/><br/>Type "N/A" if this does not apply

I understand that as part of M. T. Curry Pediatrics treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity. I hereby consent to such disclosure for these permitted uses. I also hereby consent to such disclosures via fax.

I Agree *

Signature *

Today's Date *

Emergency Contact *

Mother

Father

Other

If Other, fill in blanks below

Emergency Contact Name

Date of Birth

Relationship to Patient

Primary Phone

Insurance Information

Primary Insurance Name *

If pending insurance, type the name of the insurance the patient will have.

Member ID *

Group # *

Type 'N/A" if no group number has been assigned

Policy Type *

Provider Services Phone Number *

If no provider number, please list customer service number

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

Name *

Date of Birth *

SSN *

Secondary Insurance Name

Member ID

Group #

Type 'N/A" if no group number has been assigned

Provider Services Phone Number

If no provider number, please list customer service 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 you. 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 physician about the purpose, potential risks and benefits of any test, lab or immunization ordered for you. 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 *

First and Last Name

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 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 *

First and Last Name

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. If you do not have the copay or have not come prepared to pay past due balances, your 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 your 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 *

First and Last Name

Today's Date *

Payment Verification

Please bring your 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. 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 *

First and Last Name

Today's Date *

Late Arrivals & Missed Appointments

We ask you to arrive 15 minutes early to your appointment. If you are more than 15 minutes late you may need to be rescheduled. We confirm appointments 2 business days in advance and request a 24-hour cancellation notice. Please call our office as soon as possible if you are not able to keep an 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 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 *

First and Last Name

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 *

First and Last Name

Today's Date *

Help us make your appointment!

When was your last Well Patient Check (Physical Exam)? *

Please list any preexisting conditions: *

Type N/A if the patient has no preexisting conditions.

Please list any prescription medications you have ever taken: *

Type N/A if you have never taken prescription medication.

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 your appointment. Patients without valid form of ID will not receive any services.

Please return to currypeds.com > Home to complete the Medical Records Release Form if you are a New Patient.

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