Pediatric Consultants of Ashland and Mansfield

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1Patient Demographics > 2Medical History Form > 3Financial Policy Acknowledgement > 4HIPAA Authorization > 5Authorization for Medical Treatment of Minors
Patient Name Patient Name First Middle Last
Date Date / MM / DD YYYY
Gender
Date of Birth Date of Birth / MM / DD YYYY
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Social Security Number
Parent Email Address
How did you hear about our office?
Race
Ethnic Group
MOTHER
Name Name First Middle Last
Social Security Number
Date of Birth Date of Birth / MM / DD YYYY
Same as patient
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone
Cell Phone Cell Phone - ### - ### ####
Employer
Work Phone Work Phone - ### - ### ####
Step Father Step Father First Last
Date of Birth Date of Birth / MM / DD YYYY
FATHER
Name Name First Middle Last
Social Security Number
Date of Birth Date of Birth / MM / DD YYYY
Same as patient
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Employer
Work Phone Work Phone - ### - ### ####
Step Mother Step Mother First Last
Date of Birth Date of Birth / MM / DD YYYY
Siblings
Parents

If Divorced - Custodial/Residential Parent:
	Mom	Dad	Other
Provide court documents pertaining to medical care. Both biological parents will be able to obtain medical information unless noted in records.	Provide court documents pertaining to medical care. Both biological parents will be able to obtain medical information unless noted in records. Mom	Provide court documents pertaining to medical care. Both biological parents will be able to obtain medical information unless noted in records. Dad	Provide court documents pertaining to medical care. Both biological parents will be able to obtain medical information unless noted in records. Other

Upload Needed Court Documents:

Attach Files
If Other indicated, provide information below
Emergency Contact (If unable to reach parent) Emergency Contact (If unable to reach parent) 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 - ### - ### ####
Primary Insurance
Effective Date Effective Date / MM / DD YYYY
Name of Policy Holder Name of Policy Holder First Last
Policy/Billing #
Group #
Secondary Insurance
Effective Date Effective Date / MM / DD YYYY
Name Name First Last
Policy/Billing #
Group #
Legal Guardian (if other than parent) Legal Guardian (if other than parent) First Middle Last
Foster Parent Foster Parent First Middle Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Financial Responsibility and Assignment of Benefits

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 Acknowledgment

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)
I acknowledge receipt of the Notice of Privacy Practices

Pediatric Consultants of Ashland and Mansfield

Pediatric Consultants of Ashland and Mansfield

MOTHER

FATHER