Pediatric Consultants of Ashland and Mansfield

118+ Paperwork > 2HIPAA Authorization
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18+ Paperwork
Patient Name: Patient Name: * First Middle Last
Gender

Gender Male Female
Date of Birth: Date of Birth: * / MM / DD YYYY
Social Security #:
Address: Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone: Home Phone: - ### - ### ####
Cell Phone: Cell Phone: * - ### - ### ####
Race:
Ethnic Group:
Emergency Contact: Emergency Contact: First Middle Last
Relationship to Patient
Address: Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone: Home Phone: - ### - ### ####
Cell Phone: Cell Phone: - ### - ### ####
Name of Primary Insurance: *
Policy/Billing #:
Group#:
Name of Policyholder: Name of Policyholder: First Middle Last
Date of Birth: Date of Birth: / MM / DD YYYY
Effective Date: Effective Date: / MM / DD YYYY
Name of Secondary Insurance (if applicable):
Policy/Billing #:
Group#:
Name of Policyholder: Name of Policyholder: First Middle Last
Date of Birth: Date of Birth: / MM / DD YYYY
Effective Date: Effective Date: / MM / DD YYYY
Financial Responsibility and Assignment of Benefit
I authorize payment to Pediatric Consultants of Ashland and Mansfield for all medical and surgical benefits under the terms of my insurance. I understand that I am financially responsible for all co-payments and any charges not paid by my Insurance or Ohio Medicaid/Managed Care Program. I have received a copy of the policies and procedures. A photocopy of this authorization shall be considered as effective and valid as the original. I understand that if my child's provider, or any person employed by or under the direction and control of my child's provider(s), is directly exposed to my child's body fluids in any manner which may, according to the current Center of Disease Control guidelines, transmit the human immunodeficiency virus (HIV) or hepatitis B or C viruses, that I am deemed by law to have consented to testing for infection with HIV or hepatitis B or C viruses. I further understand, that by law, I will have deemed to consent to the release of these test results to the person who is exposed to my child's body fluids.
Notice of Privacy Practices Acknowledgement
I acknowledge Pediatric Consultants has provided their Notice of Privacy Practices, either posted or an individual copy, which provides a detailed description of the uses and disclosures allowed regarding my child's protected health information. If revisions are made, I understand that it is my responsibility to request a revised copy. (See date on posted copies)
Print Name:
Signature: *

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Date Date / MM / DD YYYY

Pediatric Consultants of Ashland and Mansfield

Pediatric Consultants of Ashland and Mansfield

Thank you for Choosing Pediatric Consultants 18+ Paperwork

Thank you for Choosing Pediatric Consultants
18+ Paperwork