PATIENT’S INFORMATION
LAST NAME / FIRST NAME & M.I. / DATE OF BIRTH
(MM/DD/YYYY) / GENDER
M F / SSN
PREFERRED LANGUAGE / RACE / Hispanic or Latino Not Hispanic or Latino Refuse to Report
MOTHER’S INFORMATION
LAST NAME / FIRST NAME & M.I. / DATE OF BIRTH
(MM/DD/YYYY) / MARITAL STATUS / SSN
MAILING ADDRESS / CITY & STATE / ZIP CODE
CELLPHONE / HOME PHONE / WORK PHONE / OCCUPATION
*EMAIL ADDRESS
FATHER’S INFORMATION
LAST NAME / FIRST NAME & M.I. / DATE OF BIRTH
(MM/DD/YYYY) / MARITAL STATUS / SSN
MAILING ADDRESS / CITY & STATE / ZIP CODE
CELLPHONE / HOME PHONE / WORK PHONE / OCCUPATION
*EMAIL ADDRESS
INSURANCE INFORMATION
MUST
COMPLETE / POLICY NAME / POLICY # / GROUP # / SUBSCRIBER NAME / SUBSCRIBER DOB / SUBSCRIBER SSN
PRIMARY
SECONDARY
TERTIARY
EMERGENCY CONTACTS
FULL NAME / PHONE # / RELATIONSHIP TO PATIENT
PLEASE NOTE THAT PERSONS LISTED ABOVE WILL HAVE ACCESS TO YOUR CHILD’S MEDICAL RECORDS AND AUTHORIZATION TO ACCOMPANY CHILD TO OFFICE VISITS.
ACKNOWLEDGEMENT: I acknowledge that all information above is accurate.
SIGNATURE OF LEGAL GUARDIAN / DATE
HOUSEHOLD
FAMILY MEMBERS / AGE
BIRTH HISTORY
BIRTH HOSPITAL / DELIVERY
Vaginal C-section / BABY WAS BORN
Term Late Early / GESTATIONAL AGE
BIRTH WEIGHT / LENGTH / HC / WAS A NICU STAY REQUIRED?
Yes No
Did mother have any illnesses or complications during pregnancy, labor or delivery? Yes No
If yes, please explain. ______
During pregnancy, did mother use any of the following? Tobacco Medications/Drugs Drink Alcohol
If yes, please list date and what was used. ______
Initial feeding: Bottle Breast
GENERAL HISTORY
Any past hospitalizations?
Any past surgeries?
Diagnosed with any medical conditions?
Any drug allergies?
Any environmental allergies or food allergies?
On any prescription medications/OTC?
Any developmental delays or concerns?
Any recent travel outside of Louisiana?
Immunizations up to date? / Yes No Unknown
Yes No Unknown
Yes No Unknown
Yes No Unknown
Yes No Unknown
Yes No Unknown
Yes No Unknown
Yes No Unknown
Yes No Unknown / If yes, what?
If yes, what?
If yes, what?
If yes, what?
If yes, what?
If yes, what?
If yes, what?
If yes, where?
FAMILY HISTORY
Please indicate which family member(s) have these problems, illnesses or diseases by using the following key:
MOTHER(M) FATHER(F) SIBLING(S) MOM’S PARENTS (MP) DAD’S PARENTS (DP) AUNT (A) UNCLE (U) OTHER (O)
ADD/ADHD / Crohn’s Disease / High blood pressure (before age 50)
Alcohol Abuse / Cystic Fibrosis / High cholesterol
Anemia / Deafness / HIV/AIDS
Anxiety / Depression / Hypertension
Asthma/Allergies / Diabetes (before age 50) / Kidney Disease
Bedwetting (after age 10) / Drug Abuse / Liver Disease
Birth Defects / Epilepsy/Convulsions / Mental Illness
Cancer / Heart Disease (before age 50) / Sickle Cell
RX HISTORY CONSENT
I hereby provide my consent for Mitchells Pediatrics to obtain my patient’s full Rx history. I understand that this inquiry will provide my physician with an accounting of patient’s medication history reported by Pharmacy Benefit Managers and retail pharmacies. I also understand that while obtaining patient’s Rx history, Mitchells Pediatrics will follow strict security protocols to align with HIPAA requirements and respect patient privacy. (All queries and responses are made automatically through secure system-to-system communications.)
Please also give the current pharmacy & location you are using:
SIGNATURE OF LEGAL GUARDIAN / DATE


PATIENT LAST NAME / PATIENT FIRST NAME / DOB
NOTICE OF PRIVACY PRACTICES
I acknowledge receipt of Mitchells Pediatrics Notice of Privacy Practices. I may request an additional copy of the privacy notice at any time. (This states how we may use and/or disclose your health information. You may refuse to sign this acknowledgement if you wish.)
INITIAL ______
Administration Only
We have made every effort to obtain written acknowledgment of receipt of our Notice of Privacy from this patient but it could not be obtained because:
The patient refused to sign.
Due to an emergency, it was not possible to obtain an acknowledgement.
We could not communicate with the patient.
Other, ______
ASSIGNMENT OF BENEFITS & RELEASE AUTHORIZATION
I hereby authorize my insurance company, including Medicare if I am a Medicare Beneficiary, to make payments to Mitchells Pediatrics for medical services or items rendered to me or my dependent by Mitchells Pediatrics. Should my insurance carrier deny Mitchells Pediatrics payment, I understand that I am financially responsible for the charges. I authorize Mitchells Pediatrics to release any and all of my records to my insurer, or any other third-party payer, legally responsible for the payment of medical expenses. I certify that the information provided or to be provided by me is correct and complete to the best of my knowledge. It is my responsibility to update any and all personal, insurance and health information.
INITIAL ______
PERMISSION TO COMMUNICATE WITH YOUR PRIMARY CARE PHYSICIAN AND/OR MENTAL HEALTH PROVIDERS
I hereby provide permission for Mitchells Pediatrics to communicate information to other health care providers (including mental health providers) as well as my insurance company if necessary. (These communications may include information about your medical treatment and mental health or substance abuse treatment. This information is limited to what is necessary for the determination of coverage and the coordination of your care. Many insurance companies require us to document whether you will allow this permission or not.)
INITIAL ______
PATIENT RIGHTS
Receive health care that is based on the American Academy
of Pediatrics standards and guidelines. / Be informed of all costs and expected payment from other resources.
Receive access to medical treatment no matter your race,
sex, creed, sexual orientation, nationality, religion,
disability or source of payment. / Confidentiality of his/her medical records.
Be free from verbal or physical abuse/harassment from staff
and receive care in a safe environment. / Access information in his/her medical records within a reasonable time frame.
Receive care that is not determined by patient’s ability to
pay for services. / Take part in decisions about the plan of your health care.
PARENT/GUARDIAN RESPONSIBILITY
Provide, to the best of your ability, the correct information needed by medical staff and/or the provider caring for the patient.
Follow instructions and guidelines given by those providing health care services.
Authority Note: Promulgated in accordance with R.S. 40:2197
Historical Note: Promulgated by the Department of Health and Hospitals
ACKNOWLEDGEMENT: I acknowledge that all information above is accurate.
SIGNATURE OF LEGAL GUARDIAN / DATE

221 Pecan Park Avenue

Alexandria, LA 71303

Phone: (318) 487-1602

MEDICAL RECORDS RELEASE FORM
I hereby authorize the release or disclosure of the following medical records to the person(s) or entity listed below:
PATIENT LAST NAME / PATIENT FIRST NAME / DOB
MEDICAL DOCTOR & CLINIC
MAILING ADDRESS / CITY & STATE / ZIP CODE
TELEPHONE NUMBER / FAX NUMBER
I am requesting the following:
All records including growth chart and vaccine records
Hospital discharge summary
Immunizations only
Laboratory reports
Operative reports
ER/Urgent Care visit with labs
Other, ______/ Requested medical records should be mailed or faxed to:
221 Pecan Park Avenue
Alexandria, LA 71303
1-877-526-9271 (fax)
  • I authorize the healthcare provider listed to use and disclose the protected health information to Mitchells Pediatrics for continuation of medical care of said patient.
  • This authorization for release of information covers all past, present and future periods.
  • I authorize the release of complete records (including those relating to mental health care, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse) as well as any additional indicated on this form.
  • This medical information may be used by the person I authorize to receive it for medical treatment or consultation, billing or claims payment, or other purposes that I may direct. This authorization shall be in force and effect for one year of the date signed, at which time this authorization expires.
  • I understand that I have the right to revoke this authorization in writing at any time.
  • I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of acquiring insurance coverage and the insurer has a legal right to contest a claim.
  • I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization.
  • I understand that information used or disclosed pursuant to this authorization may be released by the recipient and may no longer be protected by federal or state law.

LEGAL GUARDIAN (please print)
SIGNATURE / DATE