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) 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 Spanish

Renuncia de Seguro para Recién Nacidos (Newborn Insurance Waiver)

Entiendo que la siguiente exención está destinada a pacientes recién nacidos que tengan 30 días o menos. Entiendo que si no puedo proporcionar cobertura de seguro activa a partir del día 31 de vida del paciente, seré responsable del pago de los costos en los que haya incurrido hasta ese momento. (I understand that the following waiver is intended for new born patients, equal to or less than 30 days old. I understand that if I am unable to provide active insurance coverage on or after the 31st day of the patients life that I will be responsible for the payment of any costs I have incurred up to that point. )

Estimaciones de pagos por cuenta propia del recién nacido (Newborn Self-Pay Estimates)

Cheque de Recién Nacido (Newborn Check): $122.50

Seguimiento (Follow Up): $112.00

Visita Enferma (Sick Visit): $133.00

** Los totales anteriores son solo una estimación del costo de la atención y pueden diferir del monto exacto adeuda después de que se hayan prestado los servicios. **

Nombre del Paciente (Patient Name) *

Nombre y Apellido

Fecha de Nacimiento (Date of Birth) *

Fecha de Nacimiento del Paciente (Patient Date of Birth)

Entiendo que si no proporciono cobertura de seguro activa a mi hijo durante el examen de un (1) mes, seré responsable del pago de los servicios prestados durante los primeros 30 días de su vida. Entiendo que el seguro que se proporciona después del 31 ° día de vida que ha sido retroactivo puede considerarse facturable a la determinación de M.T. Curry Pediatrics y la elegibilidad para reembolsos quedan a discreción de la gerencia. ( 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.) *

Estoy de Acuerdo (I Agree)

Firma del Padre/Tutor (Parent/Guardian Signature) *

Nombre y Apellido (First & Last Name)

Fecha (Date) *

Hora (Time) *

Revisado 12/01/2020 (Revised 12/01/2020)

* Required field