Medical Release Form

If you are transferring care from another Doctor's office, we will need to request your child's medical records from that office. Please complete the following fields to the best of your ability.

Name of prior Doctor or Office *

Prior Doctor's Phone Number *

Prior Doctor's Fax Number

Prior Doctor's Office Address *

Parental Consent *

I, the parent or legal guardian, do hereby request and authorize the release of all of my child's health information that the provider has in his or her possession, including information relating to any medical history, mental or physical condition and any treatment received.

I authorize you to send my child's health record to:

Robertson Pediatrics 150 N Robertson Blvd, Ste 307 Beverly Hills, CA, 90211 (Fax) 310-659-2420 (email) [email protected]

Redisclosure: I understand that my health care provider cannot guarantee that the recipient will not redisclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information. Refusal to sign/right to revoke: I understand that signing this form is voluntary and that if I don’t sign, it will not affect the commencement, continuation or quality of my treatment. If I change my mind, I understand that I can revoke this authorization by providing a written notice of revocation. The revocation will be effective immediately upon my health care provider’s receipt of my written notice, except that the revocation will not have any effect on any action taken by my health care provider in reliance on this Authorization before it received my written notice of revocation.

Parent/Guardian Name *

Date *

Patient Information

First Name *

Middle Name

Last Name *

Patient Preferred Name

Sex

Other

Phone *

Email *

Newborn History

Please choose from the following options, if you are NOT the biological parent(s) of your child.

Adopted

Surrogacy

Other

Patient was born...

Full-Term (37wks-41wks)

Pre-Term (<37wks)

Post-Term (>41wks)

Was delivery difficult or complicated?

Yes

If YES, please explain

Birth Weight (Lbs + Ozs)

Medical History

Does your child have any MEDICATION ALLERGIES? *

Yes

If YES, then please list the medications and reactions to each medication below:

Does your child have any active MEDICAL PROBLEMS/DIAGNOSIS? *

Yes

If Yes, please explain below:

Has your child undergone any SURGERIES in the past? *

Yes

If YES, then please list all dates and types of procedures below:

Are your child's IMMUNIZATIONS up to date? *

Yes

If NO, please explain below

Please feel free to list any other concerns you might have regarding your child below:

Social History

Are the patient's mother/guardian and father/guardian... *

Married

Separated

Divorced

What is the child's custody status (i.e. joint, sole, legal guardian, etc)? *

Does your child eat a healthy, well-balanced DIET for their age? *

Yes

If NO, please explain below:

Does your child get at least 1 hour of ACTIVITY/EXERCISE per day or 5 hours per week? *

Yes

How many hours per day does your child spend in front of a SCREEN? *

Less than 2 hours

2-4 hours

4-6 hours

More than 6 hours

Are there pets in the household? *

Yes

If YES, then please list what type of pets are present in the household.

Are there any smokers in the home? *

Yes

Are there any firearms in the home? *

Yes

If there are firearms in the home, are they safely locked away? *

Yes

Family History

Sibling(s)

Please provide the names, sex, and DOB of all siblings.

SIBLING (1)

Sex

Male

Female

Other

Date of Birth

SIBLING (2)

Sex

Male

Female

Other

Date of Birth

SIBLING (3)

Sex

Male

Female

Other

Date of Birth

SIBLING (4)

Sex

Male

Female

Other

Date of Birth

Mother/ Primary Guardian

Mother/ Primary Guardian Name *

Mother/Primary Guardian Occupation *

PRIMARY HOME/MAILING ADDRESS *

Home Phone Number

Mobile phone number *

Email Address (please use LOWERCASE only) *

Father/Secondary Guardian

Name *

Father/Secondary Guardian Occupation *

PRIMARY HOME/MAILING ADDRESS *

Home Phone Number

Mobile Phone Number *

Email Address (please use LOWERCASE only) *

Emergency Contacts

Please list (2) emergency contacts that we can notify in the event that parents/guardians are not available.

CONTACT (1) *

Emergency Contact Phone # *

Emergency Contact Relationship to Patient *

CONTACT (2) *

Emergency Contact Phone *

Emergency Contact Relationship to Patient *

Insurance

Pleae note that we accept most major PPO plans (United, Cigna, Aetna, Blue Cross, Blue Shield).

Do you have Insurance? *

Yes

Primary Insured Relationship to Patient *

Primary Insured *

Primary Insured DOB *

Insurance Company Name *

Group Name *

Group Number *

Insurance ID # *

Do you have Secondary Insurance? *

Yes

Secondary Insured Relationship to Patient

Secondary Insured

Secondary Insured DOB

Insurance Company Name

Group Name

Group Number

Insurance ID #

Medical Consent Form for Child

If you anticipate that your child will be transported and supervised by individuals that are not the parents when visiting the office, then please complete the form below.

Medical Consent *

I, the parent or legal guardian, do hereby consent to any medical care determined by a physician to be necessary for the welfare of my child when accompanied and supervised by the following individuals.

Please list the NAMES and RELATIONSHIP to patient for all authorized individuals below:

Telemedicine Consent Form

HIPAA Consent Form

I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

Parent/Guardian Name *

Date *

CREDIT CARD AUTHORIZATION FORM

Our office requires that a credit card be kept on file for payment of any co-payment, co-insurance, deductible, or charge that may not be covered by your health insurance. This form will be kept confidential and only authorized staff has access to the information.

NAME, AS IT APPEARS ON CREDIT CARD:

BILLING ADDRESS: *

AMEX/DISC/MC/VISA CARD # *

VERIFICATION CODE (3 or 4 DIGITS) *

EXPIRATION DATE: *

PLEASE PROVIDE THE CARDHOLDER’S DRIVER’S LICENSE #

I acknowledge and authorize Sam Kim Physician Services, Inc to charge the above credit card account for any co-payment, co-insurance, deductible and/or charges not covered by my health insurance provider. I acknowledge that my card will be run in the event payment is not received within thirty days after I receive a statement. I agree to receive billing statements, invoices and receipts via the email I have provided to this office. If I am an uninsured patient I authorize payment at time of service. I agree to update any information regarding this credit card account.

Cardholder Name *

Date *

ADMINISTRATIVE FEE

Admin Fee Consent *

I have read and understand the administrative fee information and agree to the terms of Robertson Pediatrics annual administrative fee policy. I agree to pay this fee for items and services not covered and not reimbursed by my insurance plan.

Parent/Guardian Name *

Date

Cancellation Policy

Fees must be paid prior to the patients' next visit. *

I do hereby consent and acknowledge my agreement to the terms set forth in the CANCELLATION POLICY. I understand that this consent shall remain in force from this time forward. I acknowledge and authorize Sam Kim Physician Services, Inc to charge my credit card account for any penalties related to the failure in cancelling/rescheduling appointments within 24 hours of the visit.

Parent/Guardian Name *

Date *