Date: PATIENT REGISTRATION Chart # PLEASE PRINT FILL OUT ALL AREAS PATIENT INFORMATION CHILD S NAME BIRTHDATE SSN SEX CELL PHONE# (14 YRS & OLDER)

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PEDIATRIC ASSOCIATES OF MADISON 21 Hughes Rd., Suite 2 Madison, Alabama 35758 256-772-2037 Fax 256-772-9523 www.pedsofmadison.com Tonya T. Zbell, M.D. Robbie F. Dudley, M.D. Charlotte M. Meadows, M.D. Cynthia Dill, M.D. Elizabeth M. Bryant, M.D. Jessica Magnusson, M.D. Date: PATIENT REGISTRATION Chart # PLEASE PRINT FILL OUT ALL AREAS PATIENT INFORMATION CHILD S NAME BIRTHDATE SSN SEX CELL PHONE# (14 YRS & OLDER) 1. 2. 3. 4. PATIENT ADDRESS STREET CITY, STATE ZIP CODE PRIMARY CONTACT AND APPOINTMENT REMINDER PHONE # PARENT INFORMATION DAD S NAME DAD STEP DAD MOM S NAME MOM STEP MOM ADDRESS ADDRESS DAD S CELL PHONE # MOM S CELL PHONE # DOB SOCIAL SECURITY # DOB SOCIAL SECURITY # EMPLOYER WORK PHONE NUMBER E-MAIL ADDRESS - May we add you to our email list? yes no EMPLOYER WORK PHONE NUMBER E-MAIL ADDRESS - May we add you to our email list? yes no EMERGENCY CONTACT (FRIEND OR RELATIVE) NAME RELATIONSHIP HOME PHONE CELL PHONE REFERRED BY:

CONTINUE ON BACK >>>>>>>>> INSURANCE INFORMATION PRIMARY INSURANCE POLICY HOLDER S NAME DOB SSN COPAY PRIMARY INSURANCE CO. POLICY NUMBER GROUP NUMBER SECONDARY INSURANCE POLICY HOLDER S NAME DOB SSN COPAY SECONDARY INSURANCE CO. POLICY NUMBER GROUP NUMBER FORMS FORMS/SERVICE FEES Fees will be charged for the following forms if not requested at the time of an office visit: Blue Card - $5 Camp & Sports Physicals Forms - $10 School Medication Authorization Forms - $5 FMLA or Disability Forms - $15 Letters requested by patients - $5 (ALL FORM FEES WILL BE DUE AT THE TIME OF PICKUP.) Rush Form Fee: If a form is needed in less than 24hrs. the form fee will be doubled. SERVICES Nurse/Lab visits which are non-physician visits - $10 (Weight checks, immunization updates, allergy shots, and labs.) No-Show Appointments - $50 Minimum $22 charge for any after-hours physician call not related to an office visit PLEASE READ AND SIGN AUTHORIZATION AND ASSIGNMENT I (We), the undersigned, hereby agree to pay all amounts and charges hereafter incurred by me or members of my family for services rendered by this office. In the event of non- payment, either by insurance or by me, the balance due will increase and will include a monthly 1.5% finance charge and may include attorney and/or collection fees. Collection proceedings may result in permanent dismissal. I acknowledge and agree that Pediatric Associates of Madison, P.C. and any affiliates or vendor thereof, including collection or billing companies, may contact me by telephone or text message to any telephonic number I have provided to you, and any other telephone number associated with my account, including wireless or mobile telephone numbers. I further agree that you may use any method of contact to these numbers, such as an Automated Telephone Dialing System (ATDS) or prerecorded message. I also agree that I will notify Pediatric Associates of Madison, P.C. if I have given up ownership or control of any such telephone number. CONSENT FOR TREATMENT I authorize the doctors of Pediatric Associates of Madison, P.C., to treat my minor children listed above as they deem medically necessary. I authorize emergency medical treatment for the above-named child(ren) in the event that he/she is brought into this practice by any person other than myself. SIGNATURE OF PARENT OF LEGAL GUARDIAN PRINT NAME DATE

APPOINTMENTS We ask that you call to schedule appointments, as this is not a walk-in clinic. We strive to adhere to our office schedule as much as possible and request that you arrive for your appointments on time. Unfortunately, delays do occur. We attempt to remind all patients of pre-scheduled appointments. We will call the home number to remind; however, it is difficult for us to always be sure of confirmation by phone. Please do not depend on us to call and remind you. Please mark your calendars. We require a 3-hour notification for checkup cancellations. Failure to do so will result in a $50.00 missed appointment fee. Failure to show for any appointment will result in a $50.00 missed appointment fee. PRESCRIPTIONS Prescriptions and refills are issued during regular hours, Monday-Friday (8:00a.m-4:30p.m) Our nursing staff will call in prescription refills as time permits. Routine prescription refills should be requested no less than 24 hours prior to the date required. Please do not wait until your child s last dose of medicine to call for a refill. OFFICE HOURS/ EMERGENCIES Our office hours are Monday-Friday from 8:00a.m- 4:30p.m closed for lunch (12:15p.m-1:15p.m) We are closed on weekends and major holidays: New Years Day, Memorial Day, July 4 th, Labor Day, Thanksgiving Day, and Christmas Day. If you need emergency care at any time, please call 911 or go to the Pediatric E.R. at Women s and Children s Hospital or your nearest E.R. If you need urgent medical advice after hours please call (256) 772-2037 and the answering service will have the on-call physician return your call. We currently share weekend call with Twickenham Pediatrics and Hazel Green Pediatrics. Please remember to call during regular office hours for all non-urgent medical calls. TELEPHONE CALLS Our primary responsibility is to the patients who are in the office seeking medical care. Phone messages are returned by our nursing staff on a daily basis when time permits, based on the urgency of the call. When leaving a message, include telephone number(s) where you can be reached over the next several hours. WE RETURN CALLS FROM MULTIPLE OUTGOING PHONE LINES, SO YOUR CALLER I.D. MAY NOT DISPLAY OUR MAIN NUMBER; HOWEVER, INCOMING CALLS WILL ONLY BE RECEIVED ON OUR MAIN NUMBER (256) 722-2037. IF YOUR CHILD HAS A LIFE-THREATENING EMERGENCY, PLEASE CALL 911. Exciting new website: healthychildren.org This Children s Healthcare website is offered by the AAP and includes a symptom-based application to help parents determine the appropriate action to take: whether to treat a child at home or take him/her to the doctor or ER. It is the policy of Pediatric Associates of Madison physicians that your child(ren) receive all immunizations and checkups recommended by the AAP. Failure to comply with this recommendation will result in dismissal from our practice for noncompliance. GENERAL INFORMATION Immunization/Checkup Schedule 2 week 2 months 4 months 6 months 9 months 12 months 15 months 18 months 2 years 3 years 4 years and checkups every year thereafter. If your child needs a yearly physical, please schedule this visit during the spring or summer. Please schedule your next checkup when leaving the office. Yearly checkups are scheduled at least 3 months in advance. Immunizations and allergy shots are given on Tuesday, Wednesday, and Thursday from 9:00 a.m. to 11:30 a.m. and 1:30 p.m. to 4:00 p.m. with a nurse appointment. Service fees will be charged for the following: Physician calls that are not related to an office visit. Prior authorizations (phone or written) for medications-$5.00. Letters requested by patients to agencies- $5.00 per page. FMLA and disability forms-$10.00. Sports physical forms-$10.00. Medicine forms-$5.00 per form. Blue cards-$5.00 each. Rush fee-if forms are needed in less than 24 hours, the above fees will be doubled. If the above forms are completed at the office visit, there is no charge. A nurse fee of $10.00 is charged for the following services: Any nurse visit (weight check, immunizations, allergy shots, etc.). Lab draws (without same-day appointment). Medical Records for Second Copy: $5.00 search fee. $1.00 per page for the first 25 pages. $0.50 per page thereafter.

IMMUNIZATION POLICY It is the policy of all Pediatric Associates of Madison physicians that your child(ren) receive all immunizations required by the Advisory Committee on Immunization Practices (ACIP) of the Center for Disease Control and Prevention (CDC) or the American Academy of Pediatrics (AAP). Immunization Schedule 2 and 4 months *Pediarix, HIB, Prevnar, and Rotateq 6 months Pediarix, Prevnar and Rotateq 12 months HIB, Prevnar and Hepatitis A 15 months MMR and Varivax 18 months DTaP 2 year Hepatitis A 4-5 years **Kinrix, MMR and Varivax 10-12 years TdaP,Meningococcal and HPV *Pediarix includes DTaP, IPV, Hepatitis B *Kinrix includes DTaP, IPV The following immunizations are not currently required for school entry in the state of Alabama, but strongly recommended by the physicians of Pediatric Associates of Madison and the above organizations. Hepatitis B ( component in the Pediarix Immunization)- Required for TN Schools Rotavirus Hepatitis A Required for TN Schools Meningococcal HPV - 9 years of age and older, set of 3 vaccines. Flu vaccine is now recommended yearly, for ALL children age 6 months- 18 years of age. I acknowledge the receipt of the immunization policy of Pediatric Associates of Madison, and I agree to comply with the required immunizations. Parent/Guardian Date

Name DOB Today s Date BIRTH HISTORY: (please circle all that apply) vaginal caesarean Pre-term weeks full term weight breast bottle Complications: FAMILY HISTORY: (please circle all that apply) Diabetes Bleeding Problems Cancer Heart Disease Mental Illness High Cholesterol Seizures / Epilepsy Maternal Height Allergies Paternal Height PAST MEDICAL HISTORY: (please circle all that apply) Chickenpox Pneumonia Wheezing Seizure / Loss of consciousness Eczema Vision problems Broken bones Bedwetting Kidney / bladder problems Development / Behavior problems SURGICAL HISTORY: (please list all previous procedures) SOCIAL HISTORY: (please circle all that apply) Patient lives with: Mother Father Siblings Other: Pets smoke exposure Attends daycare / school Guns in home DAILY MEDICATIONS / HERBS / SUPPLEMENTS: (if so, please list)

Pediatric Associates of Madison 21 HUGHES RD. SUITE 2 MADISON, AL 35758 (256)772-2037 FAX (256) 772-9523 AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Each Patient Must Have a Separate Release Form PLEASE PRINT CLEARLY DATE: Patient Name: Date of Birth: Street Address: City: State: Zip: Please Check One: Sending Records to Obtaining Records From Physician/ Facility Name: _ Street Address: City: State: Zip: Phone No: Fax No: Information to be sent or received: (check all that apply) Entire Record Immunizations X-Ray Reports Laboratory Reports Other Specify: A $10 RETRIEVAL FEE AND A FEE OF.50 PER PAGE WILL BE CHARGED FOR ANY RECORDS THAT HAS TO BE RETRIEVED FROM STORAGE. I hereby Release and Authorize Pediatric Associates of Madison, P.C. to Release the Medical Records of the dependent listed (or self 18 or over) including diagnosis, treatment, prognosis, and recommendation, as well as other data pertinent to patient s treatment to the following location listed above. I hereby state that I am the child s parent or court appointed legal guardian and have the legal right to make and/or restrict healthcare decisions regarding this child, and that my parental authority has not been terminated or restricted by the courts. I understand that is authorization will expire twelve months from the date signed. Signature Date Relationship to child:

PEDIATRIC ASSOCIATES OF MADISON RIGHT TO PRIVACY CHART# Patients Name Date of Birth We at Pediatric Associates of Madison respect your child s right to privacy. Therefore, our Providers and staff will only access and use your Protected Health Information (PHI) for treatment, payment, and healthcare operations such as: 1. To provide care here in our office 2. To collect payment from your insurance company. 3. To assist your pharmacy in filling prescriptions. 4. To coordinate care with specialists to whom your child was referred. 5. When a minor reaches the age of fourteen, we can no longer discuss the child s private medical information with a parent without the child present or a written consent from the child. The exception is as follows: if a child seeks medical treatment and wishes to use the parent s insurance policy, it is the policy holder s right to know what their insurance company has been billed for. If the child does not wish for the policy holder to be given that information, they must pay cash up front for that visit. All other releases of personal information will be authorized by a signature. THIS INCLUDES YOUR IMMEDIATE FAMILY UNLESS OTHERWISE DESIGNATED BELOW. In the event of an emergency, we will contact your designated emergency contact. I authorize the staff of Pediatric Associates of Madison to discuss my child s care with the following persons: Relation Relation Relation I understand and consent to the use of my protected health information for the above purposes. Signature Date:

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