Welcome New Patients!

Welcome New Patients!
Thank you for considering Boerne Pediatrics as a health care provider for your children. Our practice is dedicated to
providing quality health care close to home. We will work with you to provide information and education about each stage
of your child's growth and development, required immunizations and other health care concerns. We follow the American
Academy of Pediatrics guidelines for well child physicals. We realize families of today have very busy schedules, please arrive
on time for your appointment and call 24 hours in advance if you need to cancel. We run on schedule, if you are not
available at your appointment time, the appointment could have been given to another child.
Our office hours are Monday-Thursday 8AM-4:30PM Friday 8AM-2PM. Please visit our website www.boernepeds.com to
learn about our office.
REGISTER AS A NEW PATIENT:
We utilize Electronic Health Records. Please complete the new patient packet and submit the following documents to our
office so we can generate a file for your child.
Patient Information Sheet
Signed Financial Policy
Completed Request for Transfer of Healthcare Records form
Copy of complete, up to date for age, vaccine record for each child
Copy of your insurance card (front and back) & government-issued photo ID
Once the above documents have been received and reviewed, a patient chart will be created and you will be notified via
phone (primary contact number) to schedule an appointment. Any changes to insurance must be submitted 24 hours in
advance. A copy of the insurance card is required to submit the claim for payment. We verify insurance coverage before
every visit. If insurance coverage is not verified, you may be subject to cash pay at time of service or be asked to re-schedule.
VACCINATIONS:
Our pediatricians dedicate their efforts to the health, safety and well-being of infants, children, adolescents and young
adults. One very important step in ensuring the health of any child is to make sure he or she receives immunizations at the
correct time. Vaccines prevent serious diseases and have helped to lower the rates of these diseases in the U.S. By getting
vaccinated, individual children receive protection from these diseases.
During each visit, we will provide you with a Vaccine Information Statement which discusses the vaccine, its benefits, and
any possible side effects. Many of your questions about vaccines can be answered ahead of time by consulting the CDC
Guide to Childhood Immunizations or the Parents' PACK from Children's Hospital of Philadelphia.
If you decline to vaccinate your child, Boerne Pediatrics is not a good medical home for you.
Thank you for choosing Boerne Pediatrics as your medical home.
Rev: 4/15
Boerne Pediatrics Patient Information Sheet
Patient Information:
________________________
________________________Preferred name if diff_______________ DOB____/____/____ M/F
Last Name
First Name
________________________
________________________Preferred name if diff_______________ DOB____/____/____ M/F
Last Name
First Name
________________________
________________________Preferred name if diff_______________ DOB____/____/____ M/F
Last Name
First Name
________________________
________________________Preferred name if diff_______________ DOB____/____/____ M/F
Last Name
First Name
Custodial Parent:
Mom Dad Both Other:
Primary Contact #: (
)
__
__________
City
Parent/Guardian Name:
/
Any Custody Concerns:______________________
Cell/Home/Work
Home Address
DOB:
__
Zip Code
Parent/Guardian Name:
/___ Phone #: (
)
C/W/H
Address (if diff. than above):
DOB:
/
/___ Phone #: (
)
C/W/H
Address (if diff. than above):
In compliance with Federal HIPAA Privacy Regulations, I authorize Boerne Pediatrics to leave a detailed message on the answering machine, voicemail,
text message or via email for appointment reminders.
Voicemail: YES/NO
Text Message: YES/NO
Email: YES/NO
Email Address:
Emergency Contact/Authorized Person: In the event a parent or legal guardian cannot bring the above listed patient(s), I hereby
authorize the following individual(s) to bring my child(ren) to appointments, be present in the exam room during examination and privy
to any pertinent medical information:
(____)
Name
Relationship to Patient
Name
Relationship to Patient
Phone #
(____)
Insurance Information:
Insurance Policies:
Insurance card information is required.
Primary Insurance:_______________________________
Employer:
Policy Holder:
Relationship to Patient:
________
DOB:
/
/____
_
Member ID #:_____________________ Group #:_________________
Ins. Po Box:_________________ City/State/Zip___________________
HIPAA & Office Policies:
Phone #
______(Initials) All charges, including co-pays, deductibles, co-insurance
and/or unpaid balances are due at the time of service. Not all services are
a covered in full. Covered benefits are determined by your insurance
provider and are only definitive once all claims are finalized. You will
receive an EOB from your insurance company. Unpaid balances become
patient responsibility and are due immediately. Balances left unpaid for
30 or more days will be assessed a $30 billing fee and turned over to our
collections service.
______(Initials) As a courtesy, we will file your insurance claims,
however, we cannot accept the responsibility of negotiating claims with
your insurance company or any person. If there is a change in insurance
coverage, you are responsible for notifying our office 24hours prior to the
appointment or you will be self-pay at the time of service. $30 rebill fee if
new insurance is provided after the appointment.
 I certify the above information is correct. I authorize Boerne Pediatrics to
provide medical services, either regular or emergency, as may be
determined by my physician to be in the best interest of my dependent minor.
 I authorize Boerne Pediatrics to review my insurance coverage with my insurance company as needed, under the HIPAA law of 1996.
 I authorize Boerne Pediatrics to release medical information to my insurance company to review coverage and/or for the processing of claims for services rendered.
 I authorize my insurance company to pay directly to Boerne Pediatrics benefits due to me out of my indemnity under the terms of my insurance policy.
 I authorize Boerne Pediatrics to release copies of my medical records to other health care providers as requested.
 I understand Boerne Pediatrics complies with all HIPAA Regulations and that a copy of the complete HIPAA policy is available for review.
 I understand that Boerne Pediatrics encourages patients to receive all immunizations as recommended by the American Academy of Pediatrics and the State of
Texas Dept. of Health. I am aware of the recommended immunization schedule. Patients who fail to adhere to the schedule may be subject to additional
administration fees.
 I agree to the above conditions and financial policy. I understand a complete copy of the financial policy is available.
 I understand I can request to inspect and copy protected health information and pay the charge associated with this service.
 I understand an up-to date copy of my child’s immunization record is to be on file with Boerne Pediatrics to schedule a Well Child Check.
Signature of Parent/Guardian:_____________________________________________
Date:_____________________________
Rev: 4/15
BOERNE PEDIATRICS FINANCIAL POLICY
Thank you for selecting Boerne Pediatrics as your healthcare provider. Our goal is to provide and
maintain a good physician-patient relationship. Letting you know in advance of our financial
policy allows for a good flow of communication and enables us to achieve our goal. Our staff will
be happy to discuss our fees and this policy with you at any time.
Please read and sign this financial policy prior to seeing the physician. Payment for services is
due at the time services are rendered. For any portion of your balance that is not covered by your insurance, or for private pay
patients, we accept: cash, check, MasterCard, Visa and American Express.
1.
Any changes to your insurance must be submitted to our office 24 hours in advance. If we are not able to determine your
insurance benefits 24hrs prior to your visit, you may be subject to cash pay at time of service or be asked to re-schedule. If
you are cash pay, a receipt will then be provided to you and you may file the claim on your own for reimbursement.
2.
Your insurance is a contract between you, your employer and the insurance company. We are NOT a party to that contract – our
relationship is with you. We will not become involved in disputes between you and your insurance company regarding
deductibles, non-covered charges, co-insurance, secondary insurance, coordination of benefits, pre-existing conditions, or
“reasonable and customary” charges other than to supply the factual information as necessary.
3.
Co-payments as well as, unmet deductible amounts are due at the time of treatment and are the responsibility of the designated
person bringing the child to the office. All charges are your responsibility whether the insurance company pays or does not pay.
Not all services are a covered benefit in all contracts. Some insurance companies and some employers decide what a covered
benefit is and what is not. Please check your insurance plan document for any questions.
4.
Once your claim has cleared, if a patient balance exists, you will receive a phone call and an email (if provided) from our office to
notify you of a balance due. You will be contacted using the information we have on file. Payment is due upon receipt of
call/email.
5.
Balances more than 30 days past date of service are considered delinquent and are subject to a $30 billing fee. These accounts
will also be turned over to our collections service unless other arrangements have been made with our office to resolve the
balance. Past due balances must be paid prior to subsequent service.
6.
There will be a $25 NSF charge on all returned checks. Post–dated checks/payments will be charged a $10 service fee.
7.
Boerne Pediatrics does not get involved in disputes between divorced parents regarding financial responsibility for their child’s
medical expenses. By signing as guarantor below, you agree to be financially responsible for the care we provide to your child,
regardless of whether a divorce decree or other arrangement places that obligation on your former spouse.
8.
Please note that all cancellations for scheduled Well Check appointments must be made at least 24 hours in advance, which allows
us to care for other patients in need of our services. Repeat cancellations/no show may be charged a $25 service fee which
will not be covered by your insurance plan.
9.
Prescription Fees:
 There is a $10.00 admin fee to re-write a controlled drug prescription (such as those written for an ADD/ADHD diagnosis)
when it is not filled before the expiration date. The voided prescription must be returned to obtain a new prescription.
 Please allow 48 hours prepare time for prescription refill requests.
10. Medical Record Fees:
 Complete Medical Records - $25.00 admin fee per chart to have it copied. Fee must be paid in advance.
 Replacement copy of Immunization Record - $10.00 fee per copy
 Daycare/Camp/Sports related form completion - $15.00 fee per form
11. Occasionally an insurance payment results in overpayment on your account and generally this balance remains on your account
as a credit for use at a future visit. You may request a refund of overpayment by notifying the Billing Manager.
12. We understand temporary financial problems may affect timely payment of your balance. We encourage you to communicate
any such problems to our Billing Manager, so we can assist you in management of your account with a payment plan.
Again, thank you for choosing Boerne Pediatrics – Keeping kids healthy every step of the way.
Child(ren) (please print each name)
___________________________
Parent/Guardian (please print)
_____
___________________________
Parent/Guardian Signature
_____
________/________/________
Date
Rev: 4/15
REQUEST FOR TRANSFER OF HEALTHCARE RECORDS TO:
BOERNE PEDIATRICS
124 E. Bandera Rd., Suite 304
Boerne, Texas 78006
830-816-5055(p) -- 830-816-5056(f)
Records may be MAILED or EMAILED
[email protected]
Today’s Date:
/
/
__
Patient’s Name:
DOB:
Patient’s Name:
DOB:
Patient’s Name:
DOB:
Patient’s Name:
DOB:
Patient Address:
City/State/Zip:
Previous Physician office:
Office Phone:
Office Fax:
* Please send Immunization Records ASAP and Medical Records within 4 weeks.*
Please check type of information to be released:
Complete Health Record
History and Physical Exam
Purpose of Request:
Treatment or consultation
Lab Test Results
Progress Notes
Other (specify)
At the request of the patient
Drug and or Alcohol and/or Psychiatric, and/or HIV/AIDS Records Release
I understand that the requested information may contain reference to or results of HIV/AIDS (Human Immunodeficiency Virus/Acquired
Immunodeficiency Syndrome) testing and/or treatment, drug and/or alcohol abuse, psychiatric care, sexually transmitted disease, Hepatitis B
or C testing, and/or other sensitive information. I authorize the release of such confidential information to the indicated party, unless prohibited
in my instructions above.
Time Limit & Right to Revoke Authorization
Except to the extent that action has already been taken in reliance on this authorization, at any time I can revoke this authorization by
submitting a notice in writing to the facility Privacy Officer at Boerne Pediatrics 124 E Bandera Rd Ste. 304. Boerne TX. 78006. Unless revoked,
this authorization will expire 180 days from date of signature.
Re-disclosure
I understand the information disclosed by this authorization may be subject to re-disclosure by the recipient and no longer by protected by the
Health Insurance Portability and Accountability Act of 1996. The facility, its employees, officers and physicians are hereby released from any
legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.
Signature of Patient or Personal Representative Who May Request Disclosure
I hereby authorize the release and transfer of my child’s complete medical record to Boerne Pediatrics. I understand that I do not have to sign
this authorization, and my treatment or payment for services will not be denied if I do not sign this form unless specified above under Purpose
of Request. I can view or receive a copy of the protected health information to be used or disclosed.
Signature:
Date:
Witness:
Identity of requestor verified
Verified by:
/
/
Photo ID
Matching Signature
Other (specify)
Rev: 4/15
TEXT MESSAGE Reminders:
Patient notifications will be sent via text message to include patient appointment reminders and patient balances due.
Please list the best contact number to receive the text message:
(
)
-
Carrier:
AT&T
Sprint
Verizon
T-Moblie
Other:
Please list all children who are patients at Boerne Pediatrics:
Last Name
First Name
DOB
Last Name
First Name
DOB
Last Name
First Name
DOB
Last Name
First Name
DOB
/
/
/
/
/
/
/
/
*We now require all patient accounts to have a credit card on file.*
Pre-Authorized Card on File Form
I authorize Boerne Pediatrics to keep my signature on file and to charge my credit card account as indicated below.
 Copayments, Deductibles, Coinsurance, Form Fees due at time of service
 Patient balances from EOB, as determined by your insurance company.
o Unpaid patient balances, past 30 days from date of service, will be subject to a $30 account
maintenance fee and subject to the family being dismissed from the practice.
I assign my insurance benefits to the provider listed above. I understand that this form is valid for
1 year unless I cancel the authorization through a written notice to Boerne Pediatrics.
* If you are experiencing financial difficulties, please contact our office to arrange a payment plan.
Credit/Debit Card On File:
□ Visa □ MasterCard
□ Amex
Cardholder Name:
Billing Address:
City/State/Zip:
Card#:
Expiration:
Cardholder Signature:
Today’s Date:
/
Security Code:
Rev: 4/15
Humana Access ® Easy Pay Consent Form
Patient Name:
I authorize


Last
First
Middle Initial
Last
First
Middle Initial
Last
First
Middle Initial
Last
First
Middle Initial
Boerne Pediatrics
To charge my Humana Access Visa debit card for my member responsibility as determined by Humana.
To credit my spending account when an overpayment of my member responsibility has occurred.
_________ All visits beginning
/
/
Date
/
Policy Holder’s Name
/
/
DOB
/
/
Card Number
/
Exp. Date
I assign my insurance benefits to the provider listed above. I understand this form is valid for this policy year, unless I cancel
the authorization through written notice to the health care provider.
/
Today’s Date
/
Signature
*Please present Humana Access ® Visa ® card at time of service.
Rev: 4/15