Acknowledgement Of Receipt Of The Policies Of Healthy Kids Pediatrics
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1HEALTHY KIDS PEDIATRICS
Acknowledgement of Receipt of the
Policies of Healthy Kids Pediatrics
Patient Name
Date of Birth: _______________________
Patient Name
Date of Birth: _______________________
Patient Name
Date of Birth: _______________________
Patient Name
Date of Birth: _______________________
I, ____________________________________________, parent/guardian of the above named child(ren) have accessed
on line or received in person a copy of the follow policies that are pertinent to my child’s care and treatment at Healthy
Kids Pediatrics policies listed below.
If you have questions or concerns with these policies, please feel free to contact us at 972-294-0808.
This form must be signed prior to services being rendered. It will become part of your
child(ren)’s permanent record with our office.
I acknowledged that I have received, read and reviewed the following policies:
Notice of Privacy Practices including Texas HB 300
**You May Refuse to Sign this Acknowledgement for the Notice of Privacy Practices Including HB300**
I have received or can access online a copy of Healthy Kids Pediatrics Notice of Privacy Practices including Texas HB 300.
Parent/Guardian Signature _______________________________ Date _________________
Financial Policy
I have read the Financial Policy. I have understood it and agree to it. I have received or have access online to this policy.
Parent/Guardian Signature _______________________________ Date _________________
Appointment Cancellation/Rescheduling Policy and the After Hours Calls to a Provider Policy
I have received or have access online, read and understand the Appointment Cancellation/Rescheduling Policy and
the After Hours Calls to a Provider Policy.
Parent/Guardian Signature _______________________________ Date _________________
Insurance and Billing Policy
I have received or have access online, read and understand the Insurance and Billing Policy.
Parent/Guardian Signature _______________________________ Date _________________
*Office Policy on Prescription Requests
I have received or have access online, read and understand the Office Policy on Prescription Requests
Parent/Guardian Signature ____________________________ Last 4 Digits of SS# _______ Date ________________
For Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, and other policies, but acknowledgement could not be
obtained because:
[ ]
Individual refused to sign
[ ]
Communications barriers prohibited obtaining the acknowledgement
[ ]
An emergency situation prevented us from obtaining acknowledgement
[ ]
Other (Please Specify)
Signature of Office Staff member
Print Form
Rev 11/2014
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