Patient Forms

Demographic Sheet- English

PATIENT INFORMATION

PARENT/GUARDIAN INFORMATION

SIBLING INFORMATION (LIST ONLY IF ESTABLISHED OR FUTURE PATIENTS)

INSURANCE INFORMATION

Please read carefully before signing below:
➢ I understand I am financially responsible for all professional charges that my child(ren) may incur. Payment for these services is due at the time of service. Patients covered under a contracted insurance plan are required to pay any co-payments, deductibles, or co-insurance at the time of service or promptly when billed. I understand that insurance cards should be presented at EVERY VISIT.
➢ I understand that hearing, vision, developmental screenings and all other in-house labs are billed separately to insurance and it is my responsibility to know what is covered under my insurance policy and I am responsible for any charges that may incur.
➢ I understand I will be listed as the guarantor and will receive the financial statements. Both parents are financially responsible regardless of custody arrangements.
➢ I hereby authorize payment of medical benefits directly to Pediatric Associates. I further authorize the release of any medical information necessary for processing the insurance claims. I understand that all costs not paid by insurance will become my responsibility unless otherwise prohibited by state or federal regulations.
➢ In the event of an emergency and I cannot be contacted, I give my permission to Pediatric Associates to treat my minor child (under age 18) in their office as required by the events of that emergency situation.
➢ I have received, or have been given the opportunity to receive, a copy of HIPAA Notice of Privacy Practices for Pediatric Associates.
➢ I give permission for telemedicine appointments, when deemed necessary.
➢ I consent to receive text, voice and/or email notices as a way to contact me about appointment reminders, billing and health notifications and announcements.
➢ I authorize Pediatric Associates to share immunization with my child(ren)’s school and the Colorado Immunization Information System (CIIS).

PEDIATRIC ASSOCIATES ALTERNATIVE CAREGIVER CONSENT Consent must be completed by a parent/legal guardian. ALL ITEMS MUST BE COMPLETED.

Please read carefully before signing below:
➢ I attest that the above-named individuals are all 18 years of age or older as of today’s date.
➢ I authorize the above-named individual(s) to consent to treatment for my child(ren). This may include, but is not limited to, consent for necessary medications, immunizations, procedures and hospitalizations. Pediatric Associates may relay any medical information, including protected health information, about my child(ren) that is necessary for the above-named individual(s) to provide informed consent to treatment.
➢ I understand the clinician will communicate his or her findings and treatment plan to the caregiver who brings the child, and under most circumstances a follow-up call to me personally should not be necessary.
➢ I agree to be responsible for any fees for services requested by the above-named individual(s) when permitted by my insurance carrier(s).
➢ I agree to hold Pediatric Associates and its staff harmless for any disagreement between the above-named individual(s) and myself regarding treatment decisions.
➢ I understand that I can revoke this authorization for any or all of these individual(s) at any time.
➢ I attest that I am the parent or legal guardian of the following child(ren) and I have the legal authority to make this agreement.

CHILD(REN) COVERED UNDER THIS CONSENT