New Patient Packet

Parent or Guardian Information

Parent or Guardian Information

Parent or Guardian Information

Appointment reminders- we will attempt to contact you to remind you of upcoming appointments.

Primary Address for all children listed below

Patient Information –list all children who are or will be seen at our clinic

Patient Information –list all children who are or will be seen at our clinic

Patient Information –list all children who are or will be seen at our clinic

Patient Information –list all additional children who are or will be seen at our clinic

Patient Information –list all additional children who are or will be seen at our clinic

Patient Information –list all additional children who are or will be seen at our clinic

Emergency Contact Information - Please list a friend or relative NOT living with you. For emergency use only.

Privacy Practices

I acknowledge that the Physician’s Notice of Privacy Practices has been offered to me. The Notice of Privacy Practices provides detailed information about how the practice may use and disclose my or my child’s confidential information. I understand that the physician has reserved the right to change his or her privacy practices that are described in the Notice. I also understand that a copy of any Revised Notice will be provided to me or made available to me.

Financial Policy

I acknowledge that I am aware of East Portland Pediatric Clinic’s financial policy and will be given a copy upon request.

Permission to Treat

I hereby authorize the physicians of East Portland Pediatric Clinic, P.C. to provide such medical services, regular or emergency, as may be determined to be in the best interest of those members of my immediate family, as listed above, who are minors. This authorization shall continue and be in full force and effect until revoked in writing by me.

Financial Policy

• HMO/PPO Plans:HMO/PPO co-payments and deductibles are due at the time of each visit.
• OREGON MEDICAID: We will run eligibility on the day of each of your visits. If for any reason your eligibility is inactive, you will be responsible for your visit. The only managed care plan EPPC participates with is FamilyCare.
• WORKERS’ COMPENSATION:EPPC does not provide care for Worker’s Compensation claims. Be certain to notify the front desk at each appointment if your visit is due to an injury covered by Workers’ compensation.
• MOTOR VEHICLE OR OTHER LIABILITY CLAIMS: East Portland Pediatric Clinic, P.C. will not bill insurance carriers for liability claims. While we understand that settlements for these claims may take many months, full payment for the visit(s) must be made at the time of service.

Understanding office visit and billing practices

The physicians and staff at East Portland Pediatric Clinic are committed to providing and maintaining the best possible care for our patients. Your review of billing practices in advance allows for good communication and common understanding.

Insurance company billing policies dictate that we differentiate between two types of services.

• Wellness Services
• Problem Oriented Services

What may be included in Wellness Services? (also known as preventative visit or physical or well child check)

What other preventive related services will be billed separately?

Problem Oriented Services

Some common examples of problem –oriented services include but are not limited to:

Notice of Referral Rights and Acknowledgement

THIS NOTICE DESCRIBES YOUR REFERRAL RIGHTS WHEN YOUR HEALTH CARE PROVIDER REFERS YOU TO ANOTHER PROVIDER OR FACILITY FOR ADDITIONAL TESTING OR HEALTH CARE SERVICES.

• A referral for a diagnostic test or health care treatment or service shall be based on the patient’s clinical needs and personal health choices.
• The patient has a choice and when referred to a facility for a diagnostic test or health care treatment or service the patient may receive the diagnostic test or health care treatment or service at a facility other than the one recommended by the health practitioner;
• If the patient chooses to have the diagnostic test, health care treatment or service at a facility different from the one recommended by a practitioner, the patient is responsible for determining the extent of coverage or the limitation on coverage for the diagnostic test, health care treatment or service at the facility chosen by the patient.
• A health practitioner shall not deny, limit or withdraw a referral solely because the patient chooses to have the diagnostic test or health care treatment or service at a facility other than the one recommended by the health practitioner.

By signing below, I acknowledge that I have read and understand my referral rights as outlined above.

Parent/Legal Guardian/Patient Request to access Patient Portal