VIERA PEDIATRICS Dr. Preeti Bimbrahw 8095 Spyglass Hill Road Suite 104 Melbourne, FL Ph (321) Fax (321)

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1 PATIENT INFORMATION PATIENT S NAME MALE (LAST) (FIRST) (MI) (NICKNAME) DOB / / SOCIAL SECURITY # - - FEMALE ADDRESS (STREET) (CITY, STATE) (ZIP CODE) HOME PHONE ( ) - CELL PHONE ( ) - WORK PHONE ( ) - PHARMACY NAME LOCATION MOTHER S NAME (OR GUARDIAN) DATE OF BIRTH SOCIAL SECURITY # - - ADDRESS ADDRESS (STREET) (CITY, STATE) (ZIP CODE) HOME PHONE ( ) - CELL PHONE ( ) - WORK PHONE ( ) - EMPLOYER OCCUPATION FATHER S NAME (OR GUARDIAN) DATE OF BIRTH SOCIAL SECURITY # - - ADDRESS ADDRESS (STREET) (CITY, STATE) (ZIP CODE) HOME PHONE ( ) - CELL PHONE ( ) - WORK PHONE ( ) - EMPLOYER OCCUPATION EMERGENCY CONTACT INFORMATION: NAME RELATIONSHIP PHONE # ADDRESS (STREET) (CITY, STATE) (ZIP CODE)

2 INSURANCE INFORMATION PRIMARY PATIENT S NAME INSURANCE CO. POLICY # POLICY HOLDER NAME DOB / / S.S. # - - INSURANCE INFORMATION - SECONDARY INSURANCE CO. POLICY # POLICY HOLDER NAME DOB / / S.S. # - - Financial Policy I understand that I am financially responsible for all charges for services to me, including co-payments, coinsurance, out-of pocket, deductibles and non covered services. I authorize the payments from my insurance company(s) according to my medical benefits be made payable to Medical Associates of Brevard for professional services rendered. I understand that I will receive statements, reflecting my account balance and that the FINAL PAYMENT of this account is my responsibility. Furthermore, should I default on payment for services rendered I agree to pay all collection costs including reasonable attorney s fee. I authorize the disclosure of my medical information to all of Medical Associates of Brevard as well as to my insurance company(s). LIFETIME SIGNATURE AUTHORIZATION: This signature and assignment is to be a continuing one, remaining in effect until revoked in writing by the undersigned. It signifies that all information given is current. SIGNED DATE / /

3 PAST DUE ACCOUNTS We will attempt to work out a payment schedule with you, however seriously delinquent accounts will be referred to a collection agency. Legal fees that we pay to secure past due balances will be added to your account. PLEASE INITIAL: RETURNED CHECKS For any returned checks, we will charge a $20 returned check fee. This fee plus the amount shown on the returned check must be paid by certified check, cash or credit card. Future payments to our office by patients who have had a returned check will need to pay by cash or credit card only. PLEASE INITIAL: HIPAA RELEASE I authorize Medical Associates of Brevard to discuss my health care information with: (Name) (Relationship) (Phone #) (Name) (Relationship) (Phone #) SIGNED DATE / / I authorize Medical Associates of Brevard to leave a detailed message on my answering machine. SIGNED DATE / / PATIENT S NAME

4 Notice of Privacy Practices I acknowledge that I have received a copy of the Provider Notice of Privacy Practices for Medical Associates of Brevard. The Provider Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Provider Notice of Privacy Practices also describes my right and the responsibilities of duties of Medical Associates of Brevard with respect to my protected health information. Print Name of Patient or Personal Representative Signature of Patient or Personal Representative Date Signature of Witness Date

5 Medical History CHILDS NAME: PERSON COMPLETING FORM & RELATIONSHIP: CHILDS DATE OF BIRTH: / / MEDICATIONS: Medications Dose How many times a day? Surgical History Please indicate any surgeries or procedures your child has had. Please include year of surgery/procedure performed. FAMILY HISTORY Please indicate if your child has a family history of any of the following: Diagnosis Family Member Diagnosis Family Member ADD/ADHD HEARING DISABILITY ALCOHOL/DRUG ABUSE HIGH CHOLESTEROL ALLERGIES HIGH BLOOD PRESSURE ASTHMA HIV/AIDS BIRTH DEFECTS LEARNING DISABILTY BLOOD DISORDERS MENTAL ILLNESS CANCER, TYPE MIGRAINES HEART DISEASE SCOLIOSIS DEAFNESS SEIZURE DISORDERS DEPRESSION SPEECH PROBLEMS DEVELOPMENT DELAY TB/LUNG DISEASE DIABETES STROKE GENETIC DISORDER THYROID DISEASE HEPATITIS/LIVER DISEASE SIGNATURE: (PARENT/GUARDIAN) PRINT NAME: DATE:

6 MEDICAL RECORDS RELEASE FORM To Whom It May Concern: Preeti Bimbrahw MD By this letter, I authorize release of my medical records to: 8095 Spyglass Hill Road, Suite 104, Melbourne FL phone: Fax: From: Name of Physician/Hospital/ Facility Fax/phone number: I would like: Complete Medical Records Name of child Childs date of birth Thank you, (Patient or Parent/Guardian Signature)

7 Viera Pediatrics Preeti Bimbrahw MD Vaccine Administration Consent Form I authorize Viera Pediatrics to administer immunizations as recommended by the American Academy of Pediatrics and CDC to my child.. (Please print Child s name) Signature of Parent/Legal Guardian Date / /

8 AUTHORIZATION FOR TREATMENT /RELEASE OF MEDICAL INFORMATION For patients UNDER 18 years of age complete this section: I, parent/legal guardian of authorize Viera Pediatrics to provide medical services to said child. I give permission for the following adults, acting as my agent, to bring my child for treatment. I authorize Viera Pediatrics, to release my child s medical information concerning the treatment that my child received to the person who brings my child for treatment. *I understand that this person may be asked to present picture ID when they bring my child for treatment. Name Date of Birth Relationship Signature of Parent/Guardian: DATE: / /

9 NO SHOW/MISSED APPOINMENT POLICY We, at, understand that sometimes you need to cancel or reschedule your appointment and there are emergencies. If you are unable to keep your appointment, please call us as soon as possible (with at least a 24-hour notice). You can cancel appointments by calling the following number To ensure that each patient is given the proper amount of time for their visit and to provide the highest quality care, it s very important for each scheduled patient to attend their visit on time. As a courtesy, an appointment reminder call to you is made/attempted 1 business day prior to your scheduled appointment. However, it is the responsibility of the patient to arrive for their appointment on time. PLEASE REVIEW THE FOLLOWING POLICY: 1)Please cancel your appointment with at least 24 hours notice. We like to fill cancelled spaces to shorten the waiting period for our patients 2) If less than a 24-hour cancellation is given this will be documented as a NO-SHOW 3) If you do not present to the office for your appointment, this will be documented as a NO-SHOW appointment. 4) After the first NO-SHOW/MISSED appointment, you will receive a phone call or letter warning that you have broken our NO-SHOW policy. will assist you to reschedule this appointment if needed. 5) If you have 2 NO-SHOW/MISSED appointments within a one year time period, you will receive a warning letter from our office and will be assessed a $25.00 no show fee. 6)If you have 3 NO SHOW/ MISSED appointments within a one year time period, you will receive a second $25.00 no show fee assessment. Dismissal from the practice will be considered. You will be notified by letter if the dismissal was approved. I have read and understand No Show/Missed Appointment Policy and understand my responsibility to plan appointments accordingly and notify appropriately if I have difficulty keeping my scheduled appointments. Patient Name Date of Birth Date Patient Signature or Parent/Guardian of minor Relationship to Patient