New Patient Form

Who Referred You to Us?

General Information

Father Guardian

First Name

Middle Name

Last Name

Date of Birth

SSN

Cell Phone

Ethnicity/Race

Employer

Employer Name

Employer Phone

Employer Address

Employer City

Employer State

Employer Zip

Mother Guardian

First Name

Middle Name

Last Name

Date of Birth

SSN

Cell Phone

Ethnicity/Race

Employer

Employer Name

Employer Phone

Employer Address

Employer City

Employer State

Employer Zip

Marital Status (choose one)

Married

Single

Divorced

What language do you speak at home?

Home Phone

Email Address

Mailing Address

Street

City

State

Zip

Physical Address

Street

City

State

Zip

Emergency Contact

Name

Phone

Patient Information

First Name

Middle Name

Last Name

Ethnicity/Race

Date of Birth

Gender

Male

Female

Insurance Information

I do not have insurance

Primary Insurance

Insurance Company Name

Insurance Address

City

State

Zip

Subscriber Name

Subscriber Date of Birth

Subscriber SSN

Insurance Effective Date

Subscriber Insurance Id

Subscriber Group Number

Secondary Insurance

Insurance Company Name

Insurance Address

City

State

Zip

Subscriber Name

Subscriber Date of Birth

Subscriber SSN

Insurance Effective Date

Subscriber Insurance Id

Subscriber Group Number

Third Insurance

Insurance Company Name

Insurance Address

City

State

Zip

Subscriber Name

Subscriber Date of Birth

Subscriber SSN

Insurance Effective Date

Subscriber Insurance Id

Subscriber Group Number

I authorize assignment of benefits to Idaho Falls Pediatrics and authorize previously named clinic to release any information requested to receive payment.

On occasion, you may wish to have your Child brought to the Clinic by someone other than a parent. Please list the names of those individuals who have your permission to bring your child in for assessment and/or treatment. A day care worker of grandparent is an example of someone you would allow to bring your child in. If you do not want anyone to be authorized, please write NONE on the name line and sign at the bottom.

The Child listed in this packet may be brought in for assessment and treatment by the following individuals:

Authorized Name

Relationship to Child

Authorized Name

Relationship to Child

Authorized Name

Relationship to Child

I authorize the release of information to the following person(s)

By signing below I also acknowledge that I received a copy of the Financial Policy and Summary of Notice of Privacy Practices.

Signature Signature is required

Date

Type your name to sign electronically

Medical Record Release

Patient Name

Date of Birth

Send Data To

Idaho Falls Pediatrics 3067 Eagle Drive, Ammon, ID 83406, or fax to: (208) 552-7521, or email: medicalrecords@secure.ifpeds.com

Doctor's Name

Phone

City

State

Zip

From

Person/Institution Sending Data

Fax Number

Phone

Address

City

State

Zip

Please Release the Following Protected Health Information

All Records

ChartNotes

X-Rays

Labs

Mental Health

If Other, please specify

The Protected Health Information is being used or disclosed for the following purpose(s): (If the patient is requesting the release, this may state "at patient's request")

Expiration Date of Release

This authorization is effective through the date below unless revoked or terminated by the patient's parents or guardian.

I understand that I have the right to revoke this authorization in writing by sending notification to the address above.

I understand that when I revoke this authorization it is not effective to the extent that the clinic has already relied on the use or disclosure of the Protected Health Information.

I understand that the Protected Health Information released pursuant to this authorization might be re-disclosed by the party who receives that information and may no longer be protected by federal or state law.

The clinic will not base my treatment or payment on whether I provide an authorization for the requested use of disclosure unless the provision of health care is solely for the purpose of creating Protected Health Information for disclosure to a third party.

I understand that I have a right to inspect or copy the Protected Health Information to be used or disclosed.

I understand that I have a right to refuse to sign this authorization.

If you have any questions concerning this form please contact the clinic manager.

Signature of Parent/Guardian Signature is required

Date

Type your name to sign electronically.

Social Determinants

In our efforts to improve your overall experience, our practice would appreciate you taking some time to answer a few questions.

This information assists us in a better patient focused approach to your care.

Circle the answer that is most appropriate to your situation.

Do you have transportation to make it to your medical appointments?

Yes No

Do you have a permanent place of residence?

Yes No

Do you have concerns that you do not have enough food for your family?

Yes No

Do you have trouble paying for your healthcare needs, including prescribed medications?

Yes No

Would you like one of our staff members to contact you to give you more information on any of the below? If yes, which one(s)?

Any additional children:

Idaho Health Data Exchange

Idaho Falls Pediatrics has chosen to participate in the Idaho Health Data Exchange also known as IHDE. If you do not want your child to participate in IHDE and choose not to have their health care information share with other medical providers involved with their care, you can opt out at any time. In order to opt out, you need to complete and sign the IHDE "Request to Restrict Disclosure of Health Information" form and mail or fax it to IHDE. The opt out forms are on our website or you can request one at the front desk. You will receive a letter of confirmation upon completing the form. You will also need to contact directly any facility you wish to also restrict your child's information with. The IHDE form is available at our front desk and online. If you do not complete this form, we may share your child's protected health information with other participating health care providers involved in your care through IHDE interface. This is a very secure statewide internet-based health information exchange, with the goal of improving the quality and coordinataion of health care in the state of Idaho.

Thank you,

Idaho Falls Pediatrics