Fillable Patient Introduction Form printable pdf download

Pediatric Associates of Northern Colorado (PANC) Patient Introduction Slip

Date: _________________

Date of Birth: ________________

Patient Name: First_______________________Middle_______________ Last________________________ (Male/Female)

Address: ___________________________________ City: ___________________ State: _______ Zip Code: ________

Parent #1 Name: ________________________________________ Employer: ___________________________________

Parent #1 Address (

): ___________________________________________________________________________

if different

Parent #2 Name: ________________________________________ Employer: ___________________________________

Parent #2 Address

: ___________________________________________________________________________

(if different)

Phone Numbers: Please list in order of preference how we should contact you (reminders, appointments, emergencies, etc.)

Preferred Contact (Home/Cell): ____________________________

Parent Work: ____________________

2nd Phone # (Parent/Patient) + (Home/Cell): _______________________

Preferred Email Address: _______________________________________________________________________________

Nearest Friend or Relative: __________________________________________ Phone: ____________________________

Name of Insurance Company: __________________________________________________________________________

Insured or Responsible Parent: _________________________ Insured or Responsible Parent DOB: _________________

Insured or Responsible Parent SS: ______________________

Ethnicity: Hispanic Non-Hispanic Declined to Specify

Race: White

Asian

Black Native American

Native Hawaii

Other Polynesian

More than one

Declined

Credit/Financial Policies

Welcome to Pediatric Associates of Northern Colorado (PANC). Please take a few minutes to review the following information. Please

sign the Credit/Financial Policies, Receipt of Notice of Privacy Practices and Authorization to File Claims with Insurance. We hope you

understand that our credit and collection policies are a necessary part of assuring the financial resources needed to maintain this medical

office for our patients and the community.

Charges for medical services at our office are due and payable at the time services are rendered. We do give a discount when paying

at the time of service. We accept cash, checks, Visa, MasterCard and Discover. For in-hospital services provided by our physicians we

will submit the charges to your insurance and allow 45 days for payment. After that time you are required to pay the charges and then

settle with your insurance company. If you have health insurance, please understand that this is an agreement between you and your

insurance company to pay a certain amount for your medical care. Our bill for medical service is an agreement between you and our

office. You are responsible for the payment of your bill regardless of the status of your insurance claim.

If unusual circumstances should make it impossible to meet our credit terms, please call or personally discuss the matter with our

Office Manager. This will help avoid misunderstandings and enable you to keep your account in good standing. Accounts 90 days past

due are referred to a collection agency, unless prior payment arrangements have been made with our office. In the event that your

account is turned over to collection you will be responsible for the collection fee in addition to your balance. Also, we will no longer be

your primary care physician. In order to keep your appointments on time it has become necessary for us to charge extra for walk-in and

unscheduled appointments (each child to be seen must have an appointment time). If you are unable to keep your appointment, please

cancel within 24 hours for well care & medication appointments. A one hour notice of cancellation is required for any other appointment.

You will be charged a fee of $25 for a sick visit, $10 for a nurse visit and $50 for a well check if you fail to meet the required cancellation

notification. There is a charge for after-hours phone calls; however no charge will be assessed if the child is seen on the next business

day. If you have any questions regarding our office policies please feel free to discuss them with our Office Manager.

Signature: _______________________________________________________ Date:________________________________________

Acknowledgement of Receipt of Notice of the Privacy Practices of PANC

I have received a copy of the Notice of Privacy Practices for PANC. This notice describes how PANC may use and disclose my protected

health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my

protected health information. Pediatric Associates reserves the right to modify the practices outlined above.

Name of Patient: _______________________________________________________________________________________________

Signature of Patient or Patient Representative: ______________________________________________________________________

Relationship of Patient Representative of Patient: _________________________________________Date:_______________________

Revised: 11/13/2014

Patient Introduction Form

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