The Pediatric Headache Center Patient Information Sheet

PATIENT INFORMATION
______________________________________________________________________________________ First name, middle initial and last name M/F Date of Birth ______________________________________________________________________________________ Address City State Zip ______________________________________________________________________________________ Home Phone Primary Physician Referring Physician ______________________________________________________________________________________ Reason for visit Allergies

PARENT INFORMATION
______________________________________________________________________________________ Fathers Name Date of Birth Employer Work# ______________________________________________________________________________________ Mothers Name Date of Birth Employer Work# I want to be contacted re: appointments by: Phone# ______________ or Email ______________________ Medical Information may be given to (circle): Mom Dad Other/Relationship ________________

EMERGENCY CONTACT (OTHER THAN PARENT)

______________________________________________________________________________________ Name Relationship Phone #

INSURANCE INFORMATION
______________________________________________________________________________________ Primary Insurance Company Subscriber Employer/Group Name ______________________________________________________________________________________ Secondary Insurance Company Subscriber Employer/Group Name

Medical Authorization: The undersigned permits Dr. Gerry and all other personnel caring for my child to examine, recommend treatment, and explain any associated risk involved. The undersigned also understand that this care may include diagnostic testing, and examinations. Financial Agreement: The undersigned agrees to be responsible for the balance of his/her account. Although an insurance claim (if applicable) will be filed with my insurance company by The Pediatric Headache Center for me, negotiating payments through my insurance company is ultimately my obligation. If I have no insurance, I understand that payment must be made at the time of service unless financial arrangements have been made PRIOR to the services. A statement will be mailed to me showing the balance due from me and it will be considered past due after 30 days. If payment in full is not possible, a payment schedule can be arranged. If payment arrangements have not been made, my account may be sent for collections. The fees associated with this will be my responsibility as well.
________________________________________________________________________________________________ Signature Date

The Pediatric Headache Center, P.C.

Patient Consent for Use and Disclosure of Protected Health Information I hereby give my consent for The Pediatric Headache Center, P.C. to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations. (The Notice of Privacy Practices provided by The Pediatric Headache Center, P.C. describes such uses and disclosures more completely.) I have the right to review the Notice of Privacy Practices prior to signing this consent. The Pediatric Headache Center, P.C. reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to: Cynthia Gerry, R.N., The Pediatric Headache Center, 400 E. Red Bridge Road, Suite 206, Kansas City, MO 64131 With this consent, The Pediatric Headache Center, P.C. may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO (Treatment, Payment & Operations), such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others. With this consent, The Pediatric Headache Center, P.C. may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential. With this consent, The Pediatric Headache Center, P.C. may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that The Pediatric Headache Center, P.C. restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to allow The Pediatric Headache Center, P.C. to use and disclose my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, The Pediatric Headache Center, P.C. may decline to provide treatment to me. _______________________________ Signature of Patient or Legal Guardian _______________________________ Print Patients Name ______________________ Date

_______________________________ Print Name of Patient or Legal Guardian, if applicable