Inland Pediatrics

Patient Information

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Consent Form

Patient Information
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(Parent Name) am the legal guardian of the aforementioned child and understand that my son/daughter will be weighed, measured and sometimes have a hemoglobin for anemia, blood pressure, glucose or urine test. I also acknowledge that my child may require one of the following procedures.

I understand that the services listed above are only performed when requested by me or if considered medically necessary. The risks and benefits, including organ damage, bleeding or continuation symptoms, are always a possible outcome. My signature here represents my consent for services and remains in place until I request a change prior to procedure(s).

Consent for Child’s Vaccination:

I have read, or had explained to me, the vaccine information sheets and understand the risks and benefits. This authorization shall apply to any and all combinations of required and recommended California State Law and CDC childhood vaccines.

I consent to Inland Pediatrics, Inc. and its staff for my aforementioned child to be vaccinated with the full vaccine series for each childhood vaccine. I understand that I may withdraw consent at any time by informing the provider.

If this consent is not signed, your child will not be vaccinated.

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Inland Pediatrics, Inc

3838 Sherman Dr Ste 7
Riverside CA 92503
(951) 688-0361

Acknowledgment of Receipt of Notice of Privacy Practices

I acknowledge that I have received a copy of the Inland Pediatrics Notice Of Privacy Practices

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(Fecha)
(Nombre del Paciente)
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(Fecha de Nacimiento)
(Padre/Guardian)

Inland Pediatrics, Inc.

COMMUNICATION CONSENT AGREEMENT

I UNDERSTAND THAT UNDER FEDERAL LAW (HIPPA), THIS MEDICAL OFFICE MAY NOT RELEASE ANY MEDICAL INFORMATION TO ANY INDIVIDUAL WITHOUT MY EXPRESSED WRITTEN PERMISSION, LAW ENFORCEMENT AND COURT ORDERS ARE TWO EXCEPTIONS TO THIS REQUIREMENT. I, THEREFORE, GIVE MY PERMISSION TO INLAND PEDIATRICS, INC TO RELEASE MEDICAL INFORMATION TO THE FOLLOWING PERSON (S):

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CHILD HEALTH HISTORY

Did you (MOM) use any non-prescribed drugs? (tobacco, alcohol, “street drugs”, over the counter or home remedies)
Did the baby go home with you from the hospital?
Did the baby receive any shots for Hepatitis B?
CHILD’S HISTORY:
Is this child adopted?
Birth Weight:
Inches

Has your child ever had:

Measles, Chickenpox, Mumps,Rubella
Skin problems
Tuberculosis or Positive TB test
Convulsions, seizures, epilepsy
Problems with eyes or vision
Diabetes
Problems with ears or hearing
Thyroid problems
Heart problems
Allergies
Asthma, bronchitis, pneumonia
Problems with developmental or school performance
Anemia, bleeding problems, blood transfusions
Serious illness or accident
Diarrhea, solling self with stool
Surgery or hospitalization
Bladder or Kidney problems, wetting self or bed
(Girls) has she started her periods? (Girls) Are there problems with her periods?

FAMILY HISTORY: Does mother (M), father (F), brother (B), sister (S), aunt (A), uncle (U), or Grandparent (GP) have:

Diabetes
High blood pressure
Epilepsy or convulsions
Bleeding disorder
Mental retardation
Tuberculosis
Heart disease
Lung problems
Cancer
Breathing problems
Kidney or urinary disease
Bone or joint problems

PARENT INFORMATION:

Age
Height:
Occupation:

HOUSEHOLD INFORMATION:

Are both parents in the home?
Does anyone in the home smoke, or use drugs or alcohol?
Do you live in a:
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INLAND PEDIATRICS

Statement of patient financial responsibility
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Inland Pediatrics appreciates the confidence you have shown in choosing us to provide for your health care needs. The service you have elected to participate in implies a financial responsibility on your part. The responsibility obligates you to ensure payment in full for our fees. As a courtesy, we will verify your insurance coverage and bill your carrier on your behalf. However, YOU are ultimately responsible for payment of your bill in full.

YOU are responsible for payment of any deductible and or copays as determined by your contract with your insurance carrier. We expect these payments in a timely manner. Many insurance companies have additional stipulations that may affect your coverage. YOU are responsible for any amount not covered by your insurance. If your insurance carrier denies any part of your claim or if you elect to receive services past your approved period YOU will be held responsible for your balance in full.

I have read and agree with the above policy regarding my financial responsibility to Inland pediatrics, for providing services to me or the above named patient. I certify that the information is the best of my knowledge true and accurate. I authorize my insurer to pay any benefits directly to Inland Pediatrics for the entire amount of the bill incurred by me or the above named patient.

NEWBORNS

Baby is usually covered under moms insurance for the first 30 days of life. Private insurance (HMO’s and PPO’s) require that you add the baby to the policy being used at the time of visit and retroactive the start date to date of birth of the baby and assign the patient to Dr. Salazar as the provider. If the baby is not added or assigned to Dr. Salazar payment will be denied by the insurance provided and the payment will become the responsibility of the parent.

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