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

Newborn Insurance Waiver

The following waiver is intended for newborn patients, equal to or less than 30 days old. Insurance is due for newborns no later than the 31st day of life. If you are unable to provide active coverage on or after the 31st day of life, you will be responsible for the payment of any costs you have incurred thus far.

Newborn Self-Pay Estimates

Newborn Check: $122.50*

Follow Up: $112.00*

Sick Visit: $133.00*

** The totals above are just an estimate of the cost of care and may differ from the exact amount owed after services have been rendered. **

Patient Name *

First and Last

Date of Birth *

Patient Date of Birth

I understand that if I do not provide active insurance coverage for my child by their one (1) month exam I will be responsible for the payment of any services rendered during the first 30 days of their life. I understand that insurance that is provided after the 31st day of life that has been backdated may be considered billable at the determination of M.T. Curry Pediatrics and refund eligibility is at the discretion of management. *

I Agree

Parent/Guardian Signature *

First & Last Name

Date *

Today's Date

Time *

Revised 12/01/2020

* Required field