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

• TIME OF SERVICE PAYMENTS:All patient portions such as co-payments & deductibles are due at time of service. Pay in person, by phone, portal or EPPC website.
• OREGON MEDICAID: We will check eligibility on the day of each of your visits. If for any reason your eligibility is inactive, you will be responsible for your visit. EPPC is not contracted with all OHP plans. You may be asked to sign a waiver assuming financial responsibility for services not covered under the state Medicaid program. (We are not contracted with WA Medicaid)
• 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, you may be required to bring your account current before a settlement is completed.

Understanding office visit and billing practices

As a Patient Centered Primary Care Home, East Portland Pediatric Clinic is 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. Medical offices that take insurance get paid by coding what they do. These codes are designated by the Center for Medicaid and Medicare Services (CMS) for all types of insurances.

• G2211 is a new code from CMS created for primary care providers to indicate that they are following patients longitudinally and are committed to caring for the whole patient over time. The pediatricians at East Portland Pediatrics take pride in providing continuity of care. This code is added to all patient encounters except those designated as Well Child Checks. Please contact your insurance company if you have questions on how they process this code.

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

Credit Card on File Authorization

I authorize East Portland Pediatric Clinic (EPPC), to charge co-payments not paid at time of service, and or unpaid 30 day balances due under $100 to the credit card listed below. For balances over $100, we will attempt to contact you to discuss payment terms. This authorization will remain in force on each of my children's accounts until they are no longer patients of EPPC or until a written request by the cardholder instructing EPPC to remove the authorization has been received. *For patients age 18 and older HIPAA restrictions apply.

Please give your card to the Front Desk to be scanned into our secure system.