New Patient Intake Form

Pediatric New Patient Intake Form

IMPORTANT INSURANCE NOTICE

Dr. Maria Louella Mariano-Nabong (Dr. Nabong) — NPI: 1275547150

Commercial Insurance: Please call your insurance to confirm network participation and verify that Dr. Nabong is in network.

AHCCCS: Please ensure Dr. Nabong is assigned as the Primary Pediatrician (PCP) prior to your visit.

Date form was completed: *

Child Information

First Name: *

Last Name: *

Date of Birth: *

Age: *

Sex:

Male

Masculino

Female

Femenino

Other

Otro

Preferred Name:

School/Daycare (if applicable):

Parent / Legal Guardian 1

Full Name: *

Date of Birth:

Relationship to Child: *

Occupation:

Phone: *

Email: *

Pediatric New Patient Intake Form

Parent / Legal Guardian 2 (if applicable)

Full Name:

Date of Birth:

Relationship to Child:

Occupation:

Phone:

Email:

Insurance Information – Primary

Insurance Company: *

Policy Holder Name: *

Policy Holder DOB: *

Member ID: *

Group #: *

Upload Your Primary Insurance ID * Accepted file types: .pdf,.doc,.docx,.jpg,.jpeg,.png

Insurance Information – Secondary (if applicable)

Insurance Company:

Policy Holder Name:

Policy Holder DOB:

Member ID:

Group #:

Upload Your Secondary Insurance ID Accepted file types: .pdf,.doc,.docx,.jpg,.jpeg,.png

Pediatric New Patient Intake Form

Consent for Treatment

I authorize Kids Health Pediatrics and its providers to evaluate, diagnose, and treat my child, including routine care, preventive services, immunizations, laboratory testing, and procedures deemed medically necessary.

Child Name: *

Guardian 1 Signature: *

Use your mouse or finger to sign in the box below.

Date *

Guardian 2 Signature:

Use your mouse or finger to sign in the box below.

Date

Financial Policy

I understand that I am financially responsible for all charges not paid by insurance, including co-pays, deductibles, co-insurance, and non-covered services. Co-pays are due at the time of service. Unpaid balances may result in delayed or declined future services.

Responsible Party Signature:

Use your mouse or finger to sign in the box below.

Date

Authorization for Release of Medical Records

I authorize the release of my child’s medical records to Kids Health Pediatrics at the selected location below.

Scottsdale Office – 5425 East Bell Road, Suite 131, Scottsdale, Arizona

Glendale Office – 5750 West Thunderbird Road, Suite F620, Glendale, Arizona 85306

Previous Pediatrician/Practice:

Signature:

Use your mouse or finger to sign in the box below.

Date:

HIPAA Notice of Privacy Practices & Acknowledgment

This notice describes how medical information about your child may be used and disclosed and how you can access this information. Information may be used for treatment, payment, healthcare operations, public health purposes, and as required by law. You have the right to inspect and obtain a copy of your child’s health records, request amendments, and receive an accounting of disclosures.

I acknowledge that I have received, read, or had the opportunity to read the Notice of Privacy Practices.

Child Name:

Parent/Guardian Signature: *

Use your mouse or finger to sign in the box below.

Date: *

KidsHealth Pediatrics

KidsHealth Pediatrics

Pediatric New Patient Intake Form

IMPORTANT INSURANCE NOTICE

Child Information

Parent / Legal Guardian 1

Pediatric New Patient Intake Form

Parent / Legal Guardian 2 (if applicable)

Insurance Information – Primary

Insurance Information – Secondary (if applicable)

Pediatric New Patient Intake Form

Social History

Medical History

Birth History

Immunizations

Pediatric New Patient Intake Form

Consent for Treatment

Financial Policy

Authorization for Release of Medical Records

HIPAA Notice of Privacy Practices & Acknowledgment

KidsHealth Pediatrics

KidsHealth Pediatrics