West Volusia Pediatrics

RICHMOND PEDIATRICS

PLEASE PRINT

PARENT INFORMATION

**PERSON RESPONSIBLE FOR BILL: MOTHER FATHER

HOME ADDRESS: ______

ADDRESSCITY/STATE/ZIP

MOM’S FIRST & LAST NAME: ______DOB: ______CELL#:______

MOM’S MAIDEN NAME: ______

DAD’S FIRST & LAST NAME: ______DOB: ______CELL#:______

HOME PHONE: ______ MARRIED DIVORCED SINGLE

EMERGENCY CONTACT (OTHER THAN PARENT):

______PH NAME RELATIONSHIP

INSURANCE INFORMATION

INSURANCE NAME: ______INSURANCE ID #: ______

GROUP#: ______EFFECTIVE DATE: ______

POLICY HOLDER’S NAME: ______POLICY HOLDER’S DOB: ______

POLICY HOLDER’S SOCIAL SECURITY#: ______

PHARMACY NAME: ______ADDRESS: ______PHONE#: ______

PLEASE READ AND SIGN THIS PAGE

FINANCIAL POLICY ACKNOWLEDGEMENT

I hereby authorize direct payment of my insurance benefits to Richmond Pediatrics or the physician individually for services rendered to my dependents by the physician or under his/her supervision. I understand that it is my responsibility to know my insurance benefits and whether or not the services I am to receive are a covered benefit. I understand and agree that I will be responsible for any co-payment, deductible and/or co-insurance due that Richmond Pediatrics is unable to collect from my insurance carrier for whatever reason. If I do not provide the practice with accurate information at the time or service, I understand that I will be responsible for payment in full for all services rendered. I understand that if my insurance carrier requires that I select a Primary Care Physician (PCP) it is my responsibility to select Dr. Buonaspina prior to my office visit.

NEWBORN BILLING POLICY

Newborns are usually covered on your insurance plan under a newborn allowance for the first 30 days from date of birth. It is your responsibility to notify your insurance carrier of your newborn. We will hold the charges for 30 days to allow your insurance carrier to enroll your newborn. If we do not receive the new insurance information within the 30 days, we will have to bill you as a self-pay patient and you will be responsible for all services rendered.

CANCELATION/NO SHOW POLICY

We understand there will be times when a scheduled appointment cannot be kept. If you need to cancel or reschedule an appointment, we request that you notify our office 24 hours in advance. Failure to provide this notice will result in a cancellation/no show fee of $35.00

FORMS POLICY

We understand many organizations such as camps, schools, sports teams require a form to be completed by your pediatrician. It may be necessary for you to drop off the form and it will take our office 48 hours to process your request. There is a form fee range of $5 to$ 20 for processing forms.

RETURNED CHECKS

Checks returned to us by the bank will be assessed a $35 returned check fee

MEDICAL RECORDS

A fee of 75 cents per page due prior to the release of record

AUTHORIZATION TO RELEASE NON-PUPLIC PERSONAL INFORMATION

I certify that I have received and read a copy of Richmond Pediatrics Patient Information Privacy Policy. I hereby authorize Richmond Pediatrics to

Release any of my dependents medical or incidental non-public personal information that may be necessary for medical evaluation, treatment,

Consultation, or the processing of insurance benefits.

LAB/BLOODWORK/DIAGNOSTIC SERVICES

I understand that I may receive a separate bill if my medical care includes lab, or other diagnostic services. I further understand that I am financially

responsible for any co-payment or balance due for these services if they are not reimbursed by my insurance company for whatever reason.

AUTHORIZATION TO MAIL, CALL OR LEAVE VOICE MAIL MESSAGES

I acknowledge that it is my right to refuse to authorize reminder calls and other types of detailed messages to be left on my voicemail and/or

answering machine. This authorization can only be revoked in writing.

Yes, please leave me a message

No, don’t leave me a message

EMAIL ADDRESS: ______

CONSENT TO TREATMENT

I have read the office policies above and I hereby consent to evaluation, testing and treatment as directed by Richmond Pediatrics.

PARENT SIGNATURE: ______DATE: ______

DR. BUONASPINA WILL NOT TOLERATE PATIENTS WHO DO NOT FOLLOW THE VACCINATION GUIDELINES OF THE AAP ACIP AND CDC.

If you desire to put your child at risk for contracting a potentially serious disease we do not want to have our patients and family members exposed to your child. Nor do we want to practice substandard medicine.