New Patient Registration Form – Child
Welcome to Celebration Family Physicians!
We look forward to working together with you towards good health.
Should you have any questions, please do not hesitate to reach out to us.
Parent / Legal Guardian Information
Authorization To Consent To Treatment Of A Minor When Parent Or Legal Guardian Is Unable To Bring Patient
I, the Parent and/or Legal Guardian of the Child / Minor stated above, authorize the above named individual(s) as my agent(s) to consent to any examination, anesthesia, medical evaluation and/or treatment, surgery evaluation and/or treatment, diagnosis or care which is deemed advisable by and is to be rendered under, the general or special supervision of a licensed physician or advanced practitioner at Celebration Family Physicians.
This authorization includes first aid, emergency care and hospital admission if such is deemed necessary by the physician or advanced practitioner at Celebration Family Physicians. It is understood that this authorization is given to provide authority and power on the part of my aforesaid agent(s) to give specific consent to any and all such evaluation, diagnostic tests, office treatment(s) including immunizations, anesthetic administration or surgical treatment(s) which a physician or other provider, in the exercise of his/her best judgment, may deem advisable. I accept responsibility for physician charges and laboratory fees. This authorization also grants to my agent(s) the power to sign for release of information to any third party payers who may be responsible for part or all of the cost of the services provided.
I give permission for the provider at Celebration Family Physicians to share any relevant health information with the person who is accompanying my child.
This authorization shall remain effective for the following dates:
Consents and Acknowledgements
Please read this section carefully and mark all checkboxes below if you understand and agree.
General Consent For Treatment
I, the patient or patient’s legal representative, agree to allow Celebration Family Physicians and its Providers to provide all health care services to me or to the individual I am representing that are routine or otherwise deemed necessary.
I understand I have the right to refuse consent to any proposed procedure or treatment at any time prior to receiving it.
I understand that any treatment involving material risks will be explained to me and that I will have the opportunity to ask questions about the associated risks, alternatives and prognosis before allowing the treatment to be performed.
I agree that no guarantees have been given to me or the individual I am representing as to the outcome of any treatment.
I authorize my provider and Celebration Family Physicians to photograph me or the individual I am representing for medically related documentation or identification purposes.
Patient To Authorize For E-Prescribe
ePrescribing is a physician's ability to electronically send an accurate, error free, and understandable prescription directly to a pharmacy from the practice. ePrescribing greatly reduces medication errors and enhances patient safety. Understanding all of the above, I, the patient or patient’s legal representative, hereby authorize the physician and/or staff of Celebration Family Physicians to enroll me in the ePrescribe Program.
Patient Authorization For Pharmacy Benefits Manager
I, the patient or patient’s legal representative, authorize the physician and/or staff of Celebration Family Physicians to request and obtain my prescription medication history from other healthcare providers, the pharmacy benefit manager and/or any third-party pharmacy payers for treatment purposes.
Patient Authorization To Release Information To Insurance Carrier
I, the patient or patient’s legal representative, authorize the providers and/or staff of Celebration Family Physicians to
release to my insurance company or its representative any information including the diagnosis and records of any treatment or examination rendered to me during medical or surgical care. I authorize and request the insurance
company to pay directly to Celebration Family Physicians the amount due for medical or surgical services. I understand
that I, the patient or patient’s legal representative, am financially responsible for any services deemed non-covered by my insurance company.
Acknowledgement Of Receipt Of Privacy Practices
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. We provide this form to comply with the Health Insurance Portability and Accountability Act (HIPPA). You have the right to review our notice before signing this consent. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy by requesting the same at the front desk.
By signing this form, you acknowledge that our practice may use and disclose PHI about you for treatment, payment, and healthcare operations. You have the right to request that we restrict, in writing, how PHI about you is used or disclosed for treatment, payment or healthcare operations.
By my signature below, I, the patient or patient’s legal representative, acknowledge that I had the opportunity to review Celebration Family Physician’s Notice of Privacy Practices.
Consent to Share Information
I choose to communicate via e-mail on matters related to my health and/or my medical treatment. I understand that any Confidential Health Information that I send to the practice using may not be secure and is sent at my own risk. I will not hold the practice, nor any of its workforce members, liable for loss of any confidentiality associated with information transmitted via e-mail. I also understand that it is not the policy of the practice to encrypt any Confidential Health Information I request to be sent to me via e-mail. Because this information is not encrypted, I understand that it is not secure. I acknowledge this risk and will not hold the practice or any of its workforce members liable for any loss of confidentiality associated with such transmissions.
Consent To Discuss Medical Information
We cannot discuss your health information with anyone other than yourself unless you authorize us to do so. Please list
below names of the individual(s) you authorize the providers and office staff of Celebration Family Physicians to discuss
Preventative vs Problem Focused Visit
We all need good preventive care! Early detection and prevention are key to maintaining good health and often saves
money. Preventive care includes exercise, eating healthy, and getting regular wellness exams with your doctor.
What are preventative services?
Typically, the following services are considered preventative services:
- Review of your health history and family health history
- Physical exam (must be one year from previous exam)
- Men and Women's Health Screenings (i.e. mammogram, pap smear)
- Screening exams (i.e. blood pressure, cholesterol screening, diabetes screening, STD screening)
- Education about wellness, diet, exercise, and prevention
- ***Other routine screening labs/services may be ordered by your physician and, as every insurance company
differs in coverage, it is the patient's responsibility to make sure these are covered prior to being completed.***
What if I have a medical problem to discuss?
Per insurance regulations, an annual preventive exam is not the same thing as a normal office visit. An annual preventive
exam does not include a discussion of a new medical problem or detailed evaluation of chronic medical conditions. Due to
those regulations and our desire to run on time, we may ask you to schedule a separate visit to address these concerns.
This will allow your physician time to adequately address your medical problems.
Instead of scheduling a separate office visit, you may have the option of addressing these chronic conditions or new
problems at the same time as your annual wellness exam. Two claims will be submitted to your insurance: one for the
annual wellness and one for an office visit addressing the chronic condition(s) or new problem(s). If you have a co-pay or
co-insurance, you will be responsible for that amount as with a normal office visit.
By signing below, you acknowledge that you have read and understand the policies stated above.