new patient application package

RUB PEDIATRICS MD PA 21110 Biscayne Blvd, Suite 308 Aventura, FL 33180 (305) 932-1007 1190 NW 95th Street, Suite 409 Miami, FL 33150 (305) 696-9490

WELCOME BIENVENIDOS Patient Information Sheet

Thank you for your patience in filling out this form so that we can better serve you. (Gracias por su paciencia en llenar este formulario, el cual nos ayudará a servirle major)

LEGAL NAME OF CHILD: TODAY’S DATE: (nombre de su hijo(a): (fecha) DATE OF BIRTH: CHILD’S SOCIAL SECURITY #: ___________________ (fecha de nacimiento) (número de su hijo(a) de social security) MOTHER’S NAME (nombre de la madre): FATHER’S NAME (nombre del padre): Parent’s Personal Information: Single (soltero) Married (casado) Divorced (divorcio) Preferred Language: English Spanish Creole Other ____________ Referring Doctor/Friend (médico o amigo que lo refiere): Local person to notify in case of emergency, if unable to reach parents (la persona mas cercana en caso de emergencia): Name of local person: _______________________________________ Phone (télefono): __________________________ I attest that the information provided above is true and correct and I understand that falsifying information is illegal and punishable to the fullest extent of the law. Signature of Parent/Legal Guardian: ___________________________________________ Date: _______________________

MOTHER’S INFORMATION (información de la madre):

HOME ADDRESS (dirección): CITY/STATE/ZIP (ciudad/estado): HOME PHONE (télefono de la casa): CELLULAR PHONE (télefono celular): WORK PHONE (télefono del trabajo): EMAIL: OCCUPATION (ocupación): DRIVER’S LICENSE # (número de licencia): SOCIAL SECURITY # (número de social security): DATE OF BIRTH: (fecha de nacimiento de la madre):

FATHER’S INFORMATION (información del padre):

HOME ADDRESS (dirección): CITY/STATE/ZIP (ciudad/estado): HOME PHONE (télefono de la casa): CELLULAR PHONE (télefono celular): WORK PHONE (télefono del trabajo): EMAIL: OCCUPATION (ocupación): DRIVER’S LICENSE # (número de licencia): SOCIAL SECURITY # (número de social security): DATE OF BIRTH: (fecha de nacimiento del padre)

Credit Card Pre-Authorization

I, ____________________________________, authorize Rub Pediatrics MD PA to keep my signature and credit card/debit card on

file to charge copayments, deductibles and coinsurances for services provided to my child,_________________________________. I agree that:

‐ This authorization is valid until cancelled in writing, sent certified, to Rub Pediatrics MD PA, 21110 Biscayne Blvd, Suite 308, Aventura, FL 33180.

‐ I will be charged the stated amount on the Explanation of Benefits (EOB) sent from my health insurance to Rub Pediatrics MD PA explaining what fees I owe. This will be charged within 7 calendar days of receiving the EOB.

‐ If health insurance benefits are assigned to Rub Pediatrics MD PA, I am responsible for the total charges incurred regardless of any insurance denial or partial payments unless other arrangements regarding fees have been made.

‐ If I have any problems or questions regarding charges made to my credit/debit card on file, I will contact the billing office at Rub Pediatrics MD PA at (305) 696-9490. I agree that I will NOT dispute any charges with my credit card company unless I have first attempted to rectify the situation with Rub Pediatrics MD PA.

‐ I further agree that if I dispute a charge with my credit/debit card, Rub Pediatrics MD PA may disclose information about my child’s visit to my credit/debit card company.

‐ I agree to update Rub Pediatrics MD PA with my new credit/debit card number if it has changed.

I have read and agreed to the above statements. SIGNATURE: ____________________________________________________

CARDHOLDER NAME: CCID:

CREDIT CARD NUMBER: EXPIRATION DATE:

CARDHOLDER BILLING ADDRESS:

CITY, STATE, ZIP:

CARDHOLDER SIGNATURE:

Primary Insurance Responsible party (persona responsable de seguro primario):

INSURANCE ID# (numero de seguro) GROUP # (numero de grupo) NAME (nombre): HOME ADDRESS (dirección): CITY/STATE/ZIP (ciudad/estado): HOME PHONE (télefono de la casa): CELLULAR PHONE (télefono celular): WORK PHONE (télefono del trabajo): EMPLOYMENT ADDRESS (dirección de su trabajo): OCCUPATION (ocupación): DRIVER’S LICENSE # (número de licencia): SOCIAL SECURITY # (número de social security): DATE OF BIRTH: (fecha de nacimiento):

Financially Responsible Party (persona responsable financieramente):

NAME (nombre): ADDRESS (dirección): CITY/STATE/ZIP (ciudad/estado): HOME PHONE (télefono de la casa): CELLULAR PHONE (télefono celular): WORK PHONE (télefono del trabajo): EMAIL: OCCUPATION (ocupación): DRIVER’S LICENSE # (número de licencia): SOCIAL SECURITY # (número de social security): DATE OF BIRTH: (fecha de nacimiento)

CONSENT FOR CHILD’S MEDICAL/EMERGENCY TREATMENT AND MEDICAL INFORMATION

Name: ___________________________________________ Mother Father Legal Guardian for child 1: ___________________________________ son daughter DOB: _____________ child 2: ___________________________________ son daughter DOB: _____________ child 3: ___________________________________ son daughter DOB: _____________ child 4: ___________________________________ son daughter DOB: _____________ In presenting my son/daughter for diagnosis and treatment, hereby voluntarily consent to the rendering of such care, including diagnostic procedures, by authorized staff of RUB PEDIATRICS MD PA or their designees, as may in their professional judgment be necessary in my absence. I hereby acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on my child’s condition. I have read this form and certify that I understand its contents. I/We hereby give my (our) consent to:

1. ___________________________________________________ (Name of Person/Agency)



who may bring my child to RUB PEDIATRICS MD PA for medical attention as described above for my child/children aforementioned. I/We acknowledge that I/We are responsible for all reasonable charges in connection with care and treatment rendered during this period. Any co-payments and/or deductibles will still need to be paid by the person bringing the child to the office at time of visit. In case of emergency, I can be reached at: ( ) _____ - _________ Signature: ___________________________________ Driver’s Lic #: ____________________________ Date: ________________________ One or all of my children have the following allergies: (if none, write name of child and state “none” in the allergies section) Name of Child: Allergies: Name of Child: Allergies: Name of Child: Allergies: Name of Child: Allergies:

Consent for Purposes of Treatment, Payment and Healthcare Operations In Accordance with HIPAA Regulations

I consent to the use or disclosure of my protected health information by Jose Mark Rub, M.D. or Beny Rub, M.D. for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Rub Pediatrics MD PA. I understand that diagnosis or treatment of me by Jose Mark Rub, M.D. or Beny Rub, M.D. may be conditioned upon my consent as evidenced by my signature on this document. I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Rub Pediatrics MD PA is not required to agree to the restrictions that I may request. However, if Rub Pediatrics MD PA agrees to a restriction that I request, the restriction is binding on Rub Pediatrics MD PA and Jose Mark Rub, M.D. and Beny Rub, M.D. I have the right to revoke this consent, in writing to Rub Pediatrics MD PA, 21110 Biscayne Blvd, Suite 308, Aventura, FL 33180, at any time, except to the extent that or Rub Pediatrics MD PA has taken action in reliance on this consent. My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health condition that identifies me, or there is a reasonable basis to believe the information may identify me. I understand I have a right to review Rub Pediatrics MD PA’s Notice of Privacy Practices prior to signing this document. The Rub Pediatrics MD PA’s Notice of Privacy Practices has been provided to me or reviewed by me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Rub Pediatrics MD PA. The Notice of Privacy Practices for Rub Pediatrics MD PA is also provided at 21110 Biscayne Blvd, Suite 308, Aventura, FL 33180 or 1190 NW 95th Street, Suite 409, Miami, FL 33150 and on the Rub Pediatrics MD PA’s website at http://rubpediatrics.com. This Notice of Privacy Practices also describes my rights and the Rub Pediatrics MD PA’s duties with respect to my protected health information. Rub Pediatrics MD PA reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by accessing the Rub Pediatrics MD PA’s website, calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment. This consent will be documented and retained in a medical chart created by Rub Pediatrics MD PA. _________________________________________ Signature of Patient or Personal Representative _________________________________________ Name of Patient or Personal Representative _________________________________________ Date _________________________________________ Description of Personal Representative’s Authority

RUB PEDIATRICS MD PA

th21110 Biscayne Boulevard, Suite 308 1190 NW 95 St, Suite 409 Aventura, FL. 33180 Miami, FL 33150 (305) 932-1007 (305)696-9490 (305) 696-6225 FAX (305) 696-6225 FAX

website: http://rubpediatrics.com email: [email protected]

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

NOTICE OF PRIVACY PRACTICES

I, __________________________________________________, as parent or legal PLEASE PRINT FULL NAME

guardian of:

Child #1: ____________________________________________ Date of Birth: ________________






agree that I have received a copy of Rub Pediatrics MD PA’s HIPAA NOTICE OF PRIVACY PRACTICES. Patient / Parent / Legal Guardian Signature: _________________________________ Date: _______________________ Witness: __________________________________

21110 Biscayne Blvd, Suite 308, Aventura, FL 33180 T: (305) 932-1007 F: (305) 696-6225 1190 NW 95th Street, Suite 409, Miami, FL 33150 T: (305) 696-9490 F: (305) 696-6225

RUB PEDIATRICS MD PAEMAIL CONSENT FORM

Name

Date :

Address

Email

Electronic or Signed Signature (Type in or sign Full Name)

By electronically signing this form: I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of e-mail between Rub Pediatrics MD PA and me, and consent to the conditions herein. In addition, I agree to the instructions outlined herein, as well as any other instructions that Rub Pediatrics MD PA may impose to communicate with patients by e-mail. Any questions I may have had were answered.

RISK OF USING E-MAIL Provider offers patients the opportunity to communicate by e-mail. Transmitting patient information by e-mail, however, has a number of risks that patients should consider before using e-mail. These include, but are not limited to, the following risks: a. E-mail can be circulated, forwarded, and stored in numerous paper an electronic files. b. E-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients. c. E-mail senders can easily misaddress an email. d. E-mail is easier to falsify than handwritten or signed documents. e. Backup copies of e-mail may exist even after the sender or the recipient has deleted his or her copy. f. Employers and on-line services have a right to archive and inspect e-mails transmitted through their systems. g. E-mail can be intercepted, altered, forwarded, or used without authorization or detection. h. E-mail can be used to introduce viruses into computer systems. i. E-mail can be used as evidence in court. CONDITIONS FOR THE USE OF E-MAIL Provider will use reasonable means to protect the security and confidentiality of e-mail information sent and received. However, because of the risks outlined above, Provider cannot guarantee the security and confidentiality of e-mail communication, and will not be liable for improper disclosure of confidential information that is not caused by Provider’s intentional misconduct. Thus, the patients must consent to the use of e-mail for patient information. Consent to the use of e-mail includes agreement with the following conditions: a. All e-mails to or from the patient concerning diagnosis or treatment will be printed out and made part of the patient’s medical record. Because they are part of the medical record, other individuals authorized to access the medical record,such as staff and billing personnel, will have access to those e-mails. b. Provider may forward e-mails internally to Provider’s staff and agent necessary for diagnosis, treatment, reimbursement, and other handling.Provider will not, however, forward emails to independent third parties without the patient’s prior written consent, except as authorized or required by law.

c. Although Provider will endeavor to read and respond promptly to an e-mail from the patient, Provider cannot guarantee that any particular e-mail will be read and responded to within any particular period of time. Thus, the patient shall not use e-mail for medical emergencies or other time sensitive matters. d. If the patient’s e-mail requires or invites a response from Provider, and the patient has not received a response within a reasonable time period, it is the patient’s responsibility to follow up to determine whether the intended recipient received the e-mail and when the recipient will respond. e. The patient should not use e-mail for communication regarding sensitive medical information, such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse. f. The patient is responsible for informing Provider of any types of information the patient does not want to be sent by e-mail, in addition to those set out in 2(e) above. g. The patient is responsible for protecting his/her password or other means of access to e-mail. Provider is not liable for breaches of confidentiality caused by the patient or any third party. h. Provider shall not engage in e-mail communication that is unlawful, such as unlawfully practicing medicine across state lines. i. It is the patient’s responsibility to follow up and/or schedule an appointment if warranted. j. Patient shall hold harmless Rub Pediatrics MD PA and it's owners and employees of any misuse of email once sent from the office. INSTRUCTIONS To communicate by e-mail, the patient shall: a. Limit or avoid use of his/her employer’s computer. b. Inform Provider of changes in his/her email address. c. Put the patient’s name in the body of the e-mail. d. Include the category of the communication in the e-mail’s subject line, for routing purposes (e.g., billing question). e. Review the e-mail to make sure it is clear and that all relevant information is provided before sending to Provider. f. Inform Provider that the patient received an e-mail from Provider. g. Take precautions to preserve the confidentiality of e-mail, such as using screen savers and safeguarding his/her computer password. h. Withdraw consent only by e-mail or written communication to Provider.

Child's Name

Child's DOB

Parent Driver's License# & DOB

This form is not valid without parent's electronic or printed signature at bottom along with driver's license and DOB.

You may electronically sign and save this form and attach it to an email and send it back to Rub Pediatrics MD PA to [email protected] or print, sign and fax it to (305) 696-6225

new patient application package

Documents