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New Patient Form 

Your submission is protected and private.

Parent #1 Information

Parent #2 Information 

General Information

Emergency Contact who is not a parent. 

Who else can bring your child to this office and make medical decisions about your child, including but not limited to: medication, vaccinations, lab work, important medical decisions which occur in the scope of pediatric practice. 

Insurnace Information: Primary Insurance 

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application. You acknowledge the form, its contents, its accuracy and that you have the legal capacity of a parent or legal gurdian of the child you are filling this for. 

BY SIGNING BELOW YOU HAVE REVIEWED AND AGREE TO OUR TERMS AND CONDITIONS, THESE INCLUDE AND ARE NOT LIMITED TO: FINANCIAL BILING POLICY, SHOW UP POLICY, LATE VISIT POLICY, ZERO PRESSURE POLICY, PRIVACY NOTICE POLICY, AND OTHER CONDITIONS WITHIN THE "TERMS AND CONDITIONS" INCLUDED HEREIN.  YOU AGREE THAT YOU HAVE HAD A CHANCE TO REVIEW SUCH POLICIES, AND WERE PROVIDED A COPY IF YOU REQUESTED ONE. 

 

BY SIGNING THIS FORM YOU PROVIDE CONSENT FOR MEDICAL TREATMENT OF YOUR CHILD 

VACCINATIONS: 

Gold Stat Pediatrics, PA values each family's personal decision on the vaccination of their children. Dr. Patel does encourage vaccinations. We do not discriminate on Vaccination Status of any child, parent/guardian, or family member. This means that some families attending Gold Star Pediatrics, PA may not be vaccinated. There is an inherent risk of exposure to different diseases, illnesses, and medical conditions when attending a practice where some patients are not vaccinated.We will do our best to facilitate a clean and sterile environment, ensure each patient room is cleaned before the next patient, and compliance of our staff with proper sanitizing procedures.You may be asked to sign a waiver acknowledging you were informed of vaccination requirements and your preference. The individual signing this form indicates and acknowledges that they understand some patients at Gold Star Pediatrics, PA may not be vaccinated and that this poses an inherent increase and risk of illness.

PRIVACY POLICY: 

THIS NOTICE DESCRIBES (1) HOW YOUR/ YOUR CHILD’S MEDICAL INFORMATION ABOUT WILL BE USED AND DISCLOSED AND(2) HOW YOU CAN GET ACCESS TO THIS INFORMATION. Notice of Privacy Practice (www.goldstarped.com/forms for FULL version)

USES AND DISCLOSURES:

Treatment: Your health information SHALL be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. This includes providers who are consulted on your condition, illnesses, lab results, and more.

Payment: Your health information SHALL be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for your services Health care operations: Your information SHALL be used as necessary to support the day-to-day activities and management of Gold Star Pediatrics, PA.

​Law enforcement: Your health information MAY be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations and to comply with government mandated reporting. WE WILL NOT DISCLOSE ANYTHING IN A CRIMINAL MATTER WITHOUT PROPER DUE PROCESS to protect the privacy of our patients.

Public health reporting: Your health information SHALL be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.

Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use of disclosure of your information, you may submit a written revocation of that authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke authorization.

Additional Uses of Information Appointment reminders. Your health information SHALL be used by our staff to send you appointment reminders.

Information about treatments. Your health information SHALL be used to send you information that you may find interesting to your treatment and management of your medical condition. We may also send you information describing other health-related products and services we believe may interest you.

Individual Rights: You have certain rights under the federal privacy standards.

These include:  The right to request restrictions in the use and disclosure of your protected health information. The right to receive confidential communications concerning your medical condition and treatment. The right to inspect your protected health information. The right to amend or submit corrections to your protected health information. The right to receive an accounting of how and whom your protected health information has been disclosed. The right to receive a printed copy of the notice. We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We are also required to abide by the privacy policies that are outlined in this notice.

Right to Revise Privacy Practices: As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal or state laws and regulations. Upon request, we will provide you with the most recently revised notice at any office visit. The revised policies and practices will be applied to all protected health information we maintain. Request to Inspect Protected Health Information You may inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting the front desk. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to delay the request. If you are requesting for your child, you must be the legal parent or guardian or authorized agent of such with our office.

Complaints: If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining any and all concerns to our Office Manager: Office Manager – GOLD STAR PEDIATRICS – 3149 Bobcat Village Center Rd., North Port, FL 34288

The individual signing this form indicates and acknowledges that they: (1) have been given the opportunity and reasonable time to review and request a copy of Gold Star Pediatrics, P.A. Notice of Privacy Practice Notice (incorporated herein) on the date indicated below, (2) that they have done so, (3) that they are signing this form with the legal authority and capacity of a patient, patient’s legal parent or guardian or a court-appointed legal representative of such, or an authorized agent of such, (4) that they have an adequate understanding of the policies incorporated herein, (5) that they are signing in good faith and (6) they are signing on the date indicated by their signature.

Acknowledgement of Financial Responsibility Policy

Thank you for choosing us as your health care provider. We are committed to providing quality care and service to all our patients. The following is a statement of our financial policy, which we require that you read and agree to prior to any treatment.

 

General: Please understand that payment of your bill is considered part of your treatment. Fees are payable when services are rendered. We accept cash, check, credit cards, and pre-approved insurance for which we are a contracted provider and are the designated Primary Care Provider (PCP), if applicable.  It is your responsibility to know your own insurance benefits, including whether we are a contracted provider with your insurance company, your covered benefits and any exclusions in your insurance policy, and any pre-authorization requirements of your insurance company. We will attempt to confirm your insurance coverage prior to your treatment. It is your responsibility to provide current and accurate insurance information, including any updates or changes in coverage. Should you fail to provide this information, you will be financially responsible.

 

Insurance: It is your responsibility to ensure you are in-network with us. If you are, we will bill your insurance. You must present a valid ID and insurance card each time you visit. You must keep all insurance information active and updated. If you do not do this, your insurance information may be wrong, and you may be responsible for the balance rendered. If we have a contract with your insurance company we will bill your insurance company first, less any copayment(s) or deductible(s), and then bill you for any amount determined to be your responsibility. This process generally takes 45-60 days from the time the claim is received by the insurance company. If we do not contract with your insurance company, you will be expected to pay for all services rendered at the end of your visit. We will provide you with a statement that you can submit to your insurance company for reimbursement. Proof of payment and photo ID are required for all patients. We will ask to make a copy of your ID and insurance card for our records. Providing a copy of your insurance card does not confirm that your coverage is effective or that the services rendered will be covered by your insurance company. Please understand some insurance coverages have Out-of-Network benefits that have co-insurance charges, higher co-payments and limited annual benefits. If you receive services are part of an Out-of-Network benefit, your portion of financial responsibility may be higher than the In Network rate.

 

Newborn Medicaid Patients: should produce proof of Medicaid coverage as soon as possible. If the child reaches 1 month of age and no proof is provided, and we are unable to verify coverage, the parent/legal guardian will be responsible for the entire bill. It is your responsibility to contact Medicaid and make sure they have everything on file for the coverage to be active. 

 

No-Show Policy: Please cancel your appointment 24 hours in advance as a courtesy to us. If you are more than 15 minutes late to your appointment, we reserve the right to re-schedule your appointment. ​If you are late more than 30 minutes it is considered a No-Show and we will re-schedule your appointment. ​Patients who have more than 3 "No Show" appointments over 2 years could be discharged from the practice. Of course, there are special circumstances, and we ask for your clear and honest communication. If you have a “No Show” appointment you must pay $25, this fee does not apply to Medicaid patients. If you are a NEW patient coming for a new patient apt, and do NOT show up or cancel within 24 hours, you will NOT be provided another appointment to establish with the practice in following 6 months minimum. 

Payment: Payment is due when the work is rendered or when the bill is given to the patient, whichever occurs first. Prompt payment is important. All co-pays and deductible are due at the visit time. Any other bills will be collected promptly as well. If you do not pay within 30 days, there will be a late charge. If you are more than 90 days behind, you will be advised to pay balance due within 30 days. If it is not paid, you will be notified that you have 1 month to find an alternative medical provider. During that 30 day grace period, medical treatment will be provided on an emergent basis only. If you over pay, a credit will be placed into your account or you can request a refund check. 

 

Returned Check Policy: If payment is made by check, and the check is returned as Non-Sufficient Funds (NSF), or Account Closed (AC), the patient's Responsible Party will be responsible for the original check amount in addition to a $35 fee. Once notified by our office, if payment is not made within 30 days, the account may be turned over to a collection agency and risk being discharged from our practice.

 

By signing below, you are agreeing to and understand the above financial agreement and you acknowledge that as the parent/legal guardian you are responsible for any charges incurred and agree to pay then as stated above.

Not being referred to this practice: 

The individual signing this form indicates and acknowledges that they: (1) have NOT been referred, pressured, coerced, forced, induced, frauded, misrepresented, and otherwise directed or guided in any way to attend Gold Star Pediatrics, PA by Dr. Patel, his agents, Gold Star Pediatrics PA or any of their staff /owners / directors / agents, or anyone associated with Gold Star Pediatrics PA, and Shore Point Hospital and their affiliates and their staff/ owners/ directors/ agents / workers / nurses/ or anyone associated with their hospital group and (2) they have been given the opportunity and reasonable time to look for other pediatricians and health care providers in the area, and (3) that they were provided a notice of other health care providers and pediatricians in the area prior to choosing Gold Star Pediatrics PA, and (4) that they have not received any incentive or promise of incentive, gift, monetary advantage or their immediate family and associated have not as a result of them choosing Gold Star Pediatrics PA, and (5) that they willingly and of free will and sound mind are choosing to apply to be a patient at Gold Star Pediatrics PA, and (6) they release Gold Star Pediatrics from any liability of self-referral under the applicable statues, and (7) that if any numerical provision herein is found to be invalid in by the courts that the other numerical provisions shall be construed to be still be fully valid, fully applicable, fully enforceable, and stand binding the patient.

The individual signing this form indicates and acknowledges that they understand and know there are other pediatricians in the area who might take them as a patient, and have been provided contact information of such, and their addresses. The individual signing this form indicates and acknowledges that they been provided the form called Acknowledgement of Non-Referral and Free Choice to Attend Gold Star Pediatrics, PA. and Acknowledgement of Obtaining Information Regarding Other Pediatricians in the Area, incorporated herein by reference, and attest that they understand the form and sign corresponding to the terms, conditions and descriptions of the form as incorporated herein by reference. 

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