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New Patient Registration

  • 1 Your Info
    Your Information
    Relationship With Patient*
    How did you hear about us?*
    Reason for visit
  • 2 Patient Demographics

    Patient Information
    Home Address
    Contact Information
    Communication Barriers(If Any)
  • 3 Emergency Contact
  • 4 Parent's Information
    Parent’s Marital Status*
    Mom's Information
    Mom's Info
    Mom's Contact
    Mom's Employer
    Mother’s Education
    Dad's Information
    Dad's Info
    Dad's Contact
    Dad's Employer
    Dad’s Education
  • 5 Insurance Detail
    Select Type
  • 6 Social Information
    Lives With
    Sibling Information
    Smoker in Household
    Alcohol use in Household
    Domestic abuse/violence(If Any)
  • 7 Past History
    Any Complication during Pregnancy
    Birth Information
    At Birth: Hep B
    Hearing Screen
    Any Hospital Admission
    Any illness
    Any medication
    Any known allergies
  • 8 Developmental History

    For infants to 24 months child, please review the Developmental Milestones of the child and list the age the milestones was achieved

    # Developmental Milestones Expected Dates List Below Date Developmental Milestone achieved or Age
    1 Head up 45 degrees; Lifts head 2 months
    2 Smile spontaneously;Smile responsively 2 months
    3 Roll over; Sit with head steady 4 months
    4 Grasp rattle; Turn to see rattling sound; Laugh 4 months
    5 Sit- No Support; Roll over 6 months
    6 Feed self; Work to obtain toy that is out of reach 6 months
    7 Pull to stand; Stand holding up 9 months
    8 Says DADA/MAMA- Nonspecific; Use single syllables 9 months
    9 Wave Bye-Bye; Imitates activities 9 months
    10 Walks well; Walk Backwards; Stops and Recovers 15 months
    11 Speak 1 word; Speak 3 words 15 months
    12 Removes clothing; Run; Walks up stairs 18 months
    13 Dresses themselves; Combines Words 24 months
  • 9 Family History
    Mother Healthy*
    Father Healthy*
    Siblings Healthy*
    Paternal Grandparents Healthy
    Maternal Grandparents Healthy
    Traveled outside USA
    Mood Disord
    High Blood Pressure
    Exposure to HIV
    Heart Disease
    Exposure to TB
    Coronary Artery Disease
    Drug Abuse
    Maternal Depression
    High Cholesterol
    Behavioral Disorder
  • 10 Family Health Habits
    How strong are your family’s religious beliefs or practices?
    How often does your family eat meals together?
    How often does your child use a seatbelt? (Car seat)?
    Does your child ride a bicycle?
    If yes, how often he/she use a helmet?
    What kind of guns are in your home?
    If you have a gun at home, is it locked up?
    Does your child use a toothpaste with fluoride in it?
    Do you help your child with tooth brushing?
    How often do you brush your teeth?
  • 11 Financial Responsibility

    Thank you for choosing us as your child’s health care provider. We are committed to providing your child comprehensive Pediatric care. Please understand that payment of your child’s bill is considered part of their treatment. The following is a statement of our financial policy which we require you to read and sign prior to any treatment.


    All professional services rendered are charged to the patient and are due at the time of service, unless other arrangements have been made in advance with our business office. Necessary forms will be completed to file for insurance carrier payments.

    If a check is returned to us for any reason, your child’s account will be charged the amount of the check plus a $ 25.00 returned check fee. Parents will be responsible for any fees incurred from collection agencies and/or legal services hired by POWERS PEDIATRICS to secure payment for services.


    Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual or customary rates.


    WE CANNOT BILL YOUR INSURANCE COMPANY UNLESS YOU GIVE US A COPY OF YOUR CHILD’S INSURANCE CARD. Without a copy of the card, you will be responsible for 100% of the charges on that date of service. We will file to your insurance company; however, if you must pay a percentage of the bill, it must be paid at the time of service. All co-pays are due at the time of service.

    The balance is your responsibility whether your insurance company pays or not. Your insurance policy is a contract between you and your insurance company. Please be aware that some, and perhaps all of the services provided may be non-covered services and not considered reasonable according to your insurance policy.

    According to Florida State statutes, an HMO has 45 days to process and pay a correct claim. If your insurance has not paid your child’s claim in full within 6 months, you will be responsible for the bill within 10 days of receipt of your statement.

    We will mail 2 statements to you before the account is turned over to a collection agency. If you are unable to pay the balance in full, we can arrange a payment plan for you which you will sign. A copy of the payment plan will be given to you and copy will be kept in your child’s chart. If you default on your payment plan, the account will be forwarded to a collection agency.

    In the event that your insurance changes, it is your responsibility to notify us as we may be non participating providers. Failure to do so will result in you being responsible for all charges incurred. It is not the responsibility of POWERS PEDIATRICS to ensure we are providers. Our main concern is the health of our patients.

    Regarding HMO, Managed Care and Medicaid plan, you are responsible for making sure that our practice and/or doctors are listed as your child’s Primary Care Physicians. Failure to do so will result in you being responsible for all charges incurred.

    Assignment of Benefits

    I hereby assign all medical, dental and surgical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrieres), including Medicare, private insurance and any other health/medical and dental plan, to issue payment check(s) directly to POWERS PEDIATRICS for medical and dental services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.

    Authorization to Release Information

    I hereby authorize POWERS PEDIATRICS to: (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims for the period of lifetime. This order will remain in effect until revoked by me in writing.

    I have requested medical services from POWERS PEDIATRICS on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

    I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.

    Your Signature Below Confirm that you fully understand POWERS PEDIATRICS financial policy.

    Do you have trouble affording the care or prescriptions prescribed?
    Signee Info
  • 12 HIPAA Patient Questionnaire
    1. Please list the family members or other person(s), if any, whom we may inform about your general medical condition and your diagnosis (including treatment, payment and health care operations):
    2. Please list the family members or others, if any, whom we may inform about your medical condition ONLY IN AN EMERGENCY.
    3. Please print the address of where you would like your billing statements and/or correspondence from our office to be sent if other than your home. (Confidential Communications)
    4. Please indicate if you want all correspondence from our office sent in a sealed envelope marked “CONFIDENTIAL”.
    5. Please print the telephone number or email address where you want to receive calls about your appointments, labs and x-rays results or other health care information:
    6. Can confidential messages (ie., appointment reminders) be left on your telephone answering machine or voicemail?

    I understand the Privacy Protection Act and have been offered a copy of the Organization’s Notice of Privacy Practices updated for the HITECH Omnibus Rule of 2013.

  • 13 Consent for Treatment

    I consent to the use of disclosure of my protected health information by Powers Pediatrics for the purpose of diagnosing or providing treatment to me/my child, obtaining payment for me/my child’s health care bills or to conduct health care operations of Powers Pediatrics.

    I have the right to revoke this consent, in writing, at any time, except to the extent that Powers Pediatrics has taken action in reliance on this consent.

    Me/my child’s “protected health information” mean health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to me/my child, or there is a reasonable basis to believe the information may identify me/my child.

    POWERS PEDIATRICS has an established privacy policy which is displayed in this office and I can request a printed copy of this policy.

    Signee Information