New Patient Packet Please call our office at 503-255-3544 before filling out this form. We want to ensure we are contracted with your insurance provider and find out if you have or need to schedule an appointment for your child. Step 1 of 13 7% Parent or Guardian InformationParent/Guardian (Primary Contact) Legal Name First Last Relation to Patient BirthdayMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SSNLive w/ Patient? Yes No Preferred Phone #Phone # Type Cell Home Work Second Phone #Phone # Type Cell Home Work Other Phone #Phone # Type Cell Home Work Parent or Guardian InformationParent/Guardian (Secondary Contact) Legal Name First Last Relation to Patient BirthdayMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SSNLive w/ Patient? Yes No Preferred Phone #Phone # Type Cell Home Work Second Phone #Phone # Type Cell Home Work Other Phone #Phone # Type Cell Home Work Parent or Guardian InformationEmail (We only have capability to list one email per family) Appointment reminders- we will attempt to contact you to remind you of upcoming appointments. If you wish to receive an additional automated reminder, please choose ONLY ONE of the options below Text Phone Call Email as written above Text #Phone Call #Primary Address for all children listed below Street Address Apt City State Zip Patient Information –list all children who are or will be seen at our clinic Legal First Name Legal Last Name MI BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex/Gender Doctor Ethnicity Hispanic or Latino Not Hispanic or Latino Preferred Language English Other Race American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Type "Other" language below Patient Information –list all children who are or will be seen at our clinic Legal First Name Legal Last Name MI BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex/Gender Doctor Ethnicity Hispanic or Latino Not Hispanic or Latino Preferred Language English Other Race American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Type "Other" language below Patient Information –list all children who are or will be seen at our clinic Legal First Name Legal Last Name MI BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex/Gender Doctor Ethnicity Hispanic or Latino Not Hispanic or Latino Preferred Language English Other Race American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Type "Other" language below Do you have more than 3 children? Yes No Patient Information –list all additional children who are or will be seen at our clinic Legal First Name Legal Last Name MI BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex/Gender Doctor Ethnicity Hispanic or Latino Not Hispanic or Latino Preferred Language English Other Race American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Type "Other" language below Patient Information –list all additional children who are or will be seen at our clinic Legal First Name Legal Last Name MI BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex/Gender Doctor Ethnicity Hispanic or Latino Not Hispanic or Latino Preferred Language English Other Race American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Type "Other" language below Patient Information –list all additional children who are or will be seen at our clinic Legal First Name Legal Last Name MI BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex/Gender Doctor Ethnicity Hispanic or Latino Not Hispanic or Latino Preferred Language English Other Race American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Type "Other" language below Emergency Contact Information - Please list a friend or relative NOT living with you. For emergency use only. Name First Last Relation Phone #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. Signature Relationship to Patient DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920How did you hear about our clinic? Please check all that apply. Friend Family Parent seen here as child Web search Hospital OB-Gyn Advertisement Established Family Other child already a patient Insurance company Financial PolicyPATIENT RESPONSIBILITY:Patients are responsible for all charges resulting from treatment provided by East Portland Pediatric Clinic (EPPC.) As a service to you we will bill most insurance carriers directly; however primary responsibility for the account is yours. Payment is due within (30) days of statement billing unless financial arrangements are made. Should your account be placed in a collection status, you will be responsible for all agency and/or legal fees incurred.INSURANCE:You are responsible for deductibles, co-pays, non-covered services, coinsurance and items considered “not medically necessary” by your insurance company. You will be asked to pay co-payments and deductible amounts as services are rendered. Please contact your insurance company to determine if we are a preferred provider on your plan and be aware of your benefits. It is not possible for our staff to know all patient benefits. The remaining balance should be paid within 30 days of receipt of EPPC statement. If you make a payment exceeding your balance, it is your responsibility to watch your insurance explanation of benefits and ask us for a refund when due. We will attempt to contact you if this should occur. Accounts with personal credit balances will not be refunded unless all other charges have been processed by insurance. As a courtesy, we will bill your primary and secondary insurance carrier for you if we are contracted on your plan. Providing correct insurance billing information is the responsibility of the parent/patient. Patients are required to present current insurance identification card(s) to each appointment. 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. DIVORCED PARENTS Both parents are equitably responsible for their child(ren)’s healthcare expenses, unless a court mandate stipulates otherwise. Account demographic changes may be made by either parent unless legally specified. Disputes between parents will not be arbitrated by EPPC. If further questions please request a copy of our divorced or separated parent/guardian policy also available on our website. LATE CHARGES All charges are due and payable within 30 days of the first billing unless you arrange a budget payment plan with our billing department. Payment arrangements will not be made for elective appointments i.e. well exams and circumcisions. The parent/guardian(s) will bear the cost of collection and/or court costs and reasonable legal fees should this be required. Accounts referred to our outside agency due to lack of payment will be charged a $100 collection fee that will not be billed to insurance. LATE CHARGES Contact your insurance company as soon as possible after your child is born. Most health plans allow you 30 days to add your newborn. If you have coverage through Oregon Health Plan, please contact your caseworker immediately. Oregon Health Plan should provide you with an ID#. You may be asked to sign a waiver assuming financial responsibility for services not covered under the state Medicaid program. Please be advised, the only managed care plan EPPC participates with is FamilyCare. CHECKS RETURNED FOR INSUFFICIENT FUNDS: It is our clinic’s policy to charge all patients a $25.00 fee for checks that are returned unpaid by the bank. If checks return frequently, all further payments may be required to be paid in cash. MISSED APPOINTMENTS: Please call 24 hours in advance to cancel or reschedule appointments. EPPC has a policy of charging $50.00 for missed appointments. We may also choose to discharge a patient from care for repeated incidents of missed appointments. PAYMENT OPTIONS: We accept Cash, Checks, Money Orders, Visa, Mastercard, AmEx & Discover. We do not accept traveler’s checks. Credit and Debit payments may also be made on our website: www.eastportlandpeds.com It is your responsibility to ask for receipts as payments are made if you need them for tax purposes. LAB WORK:Limited lab tests are performed in our office. Please be aware of the preferred labs for your insurance carrier. You will be responsible for any expenses incurred resulting from lab tests. AFTER HOURS:After hours and weekend care are more costly to provide, so there is an additional charge during those hours. If you have any questions about the above policy, please speak to our billing office. We reserve the right to update this policy at any time. Financial Policy Consent I agree to the financial policy.I have read a copy of the financial policy for East Portland Pediatric Clinic, P.C. I accept this policy for my child’s treatment with East Portland Pediatric Clinic, P.C. I agree to pay for all services rendered in accordance with the terms and conditions set forth in the financial policy of East Portland Pediatric Clinic, P.C. 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) Age appropriate history Age appropriate medical exam Anticipatory guidance (such as reducing fall risks for early walkers) Review and interpretation of any recommended labs Preventive counseling (such as proper nutrition) Review of vaccine history What other preventive related services will be billed separately? Vaccine products* Routinely recommended labs** Vaccine administration services (including counseling) Screenings (e.g., vision, hearing or developmental screens) During wellness visits we perform all recommended screenings appropriate to age and gender and seek to uncover any conditions that would lead to suboptimal health in the years to come. These screens are recommended by the American Academy of Pediatrics. The use of screening tools also allows us to begin treating conditions in their earliest stages. These screens are considered a problem oriented service by most insurance plans and therefore may generate cost sharing in the form of a copayment, co-insurance, and/or deductible. The Affordable Care Act makes many wellness and/or preventative services covered in full by most insurance plans. However, this is not true of many problem-oriented services. Management of medical diagnoses, including the need for medication refills of any sort, are categorized by insurance companies as problem-oriented services. Evaluation and/or management of any complaint and/or symptom offered by a patient or identified upon questioning during a wellness exam constitutes a problem- oriented service which may result in your insurance company processing your claim using both wellness benefits and problem oriented benefits. Problem Oriented Services Some common examples of problem –oriented services include but are not limited to: Illness addressed (ears, eyes, nose, throat, cough, fever, etc) Chronic conditions addressed e.g., obesity, asthma, ADHD/ADD Behavior Concerns GYN concerns Lactation Services Suture Removal Anxiety/Depression Wart removal Nails Excision Examples of screening services include but are not limited to: Cholesterol, Lead, Hemoglobin Screening Vision tests Hearing screening Developmental Screenings (ie: 9, 12mo questionnaires) Spirometry Mental Health questionnaires Adolescent questionnaire Autism screening (MCHAT) ****all laboratory, radiology and/or pathology services performed or referred by our providers may result in additional bills and/or charges from other companies that may include but are not limited to: such as Quest laboratories, Epic Imaging, Adventist lab etc.. You may receive separate billing statements for these services. Our medical practice wants to provide the most up to date, comprehensive care possible, which is why we address these issues during wellness visits. Additionally, we try to eliminate the need for the patient to return to the office, whenever possible. It is the responsibility of the policy holder to be aware of their insurance plan’s benefits and coverage. Deductible, copay, coinsurance or out of pocket expenses agreed upon between you and your insurance company are out of our control. 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. In accordance with Oregon law, when you are referred for care outside of our clinic, we {East Portland Pediatric Clinic, P.C.} are required to notify you that you may have the test or service done at a facility other than the one recommended by your physician or health care provider. Oregon law says (ORS 441.098): 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.Patients over age of 18, Parent, Guardian, Responsible Party or Legal Representative signature DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Signature for the following patient(s).Name 1 DoBMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name 2 DoBMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name 3 DoBMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name 4 DoBMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name 5 DoBMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Description of Representative’s Authority Parent/Legal Guardian/Patient Request to access Patient Portal User Requesting Access Please type: Parent/Legal Guardian OR if self, Patient First & Last Name Notifications (including initial sign in link) can be sent to one of the below choices: Text Email Text Phone #Email By signing below, I certify that I am the parent or legal guardian of the patient(s) listed below and I understand that my portal access (other than messaging and family account balance) will be revoked once the patient is 18 years old. Signature of User Requesting Access: Patient Name First Last DoBMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Relationship to user Patient Name First Last DoBMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Relationship to user Patient Name First Last DoBMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Relationship to user Patient Name First Last DoBMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Relationship to user Patient Name First Last DoBMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Relationship to user Δ
