Pediatric Consultants of Ashland and Mansfield
Pediatric Consultants of Ashland and Mansfield
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18+ Paperwork
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HIPAA 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
United States
United Kingdom
Canada
Australia
Netherlands
France
Germany
-------
Afghanistan
Albania
Algeria
Andorra
Antigua and Barbuda
Argentina
Armenia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
Gabon
Gambia
Georgia
Ghana
Greece
Grenada
Guatemala
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Guinea
Guinea-Bissau
Guyana
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Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
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Kenya
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Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Country
Home Phone:
Home Phone:
-
###
-
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####
Cell Phone:
Cell Phone:
*
-
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-
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####
Race:
American Indian/Alaska Native Asian
Black/African American
White
Native Hawaiian/Other Pacific Islander Other
Declined
Ethnic Group:
Hispanic or Latino
Non-Hispanic or Latino
Decline
Emergency Contact:
Emergency Contact:
First
Middle
Last
Relationship to Patient
Address:
Address:
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
United States
United Kingdom
Canada
Australia
Netherlands
France
Germany
-------
Afghanistan
Albania
Algeria
Andorra
Antigua and Barbuda
Argentina
Armenia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
Gabon
Gambia
Georgia
Ghana
Greece
Grenada
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
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:
*
Clear
Date
Date
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MM
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DD
YYYY