New Patient Registration

New Patient Registration

Piedmont Pediatrics|105 Collier RD. NW| Ste. 4060|Atlanta, GA 30309 404-351-6662 | www.piedmontpediatrics.org
Thank you for taking the time to complete the new patient registration form. Registering your child beforehand will save time on appointment day and you will have fewer forms to complete when you arrive.

Before we start, please make sure you have the following information available:
- Insurance card
- Billing information
- Contact information of/for your child(ren)'s previous doctor if you are transferring practices
Click next if you are ready to begin.

Family Demographics

Parent/Guardian Information
Parent/Guardian Name:*

First NameLast NameSuffix
Date of Birth*

MonthDayYear
Parent/Guardian
What is your relationship with the patient?*
Address*

Street Address

Street Address Line 2/APT/Suite

CityState / Province

Postal / Zip Code
Phone Number (cell)*
Email
example@example.com
Employer
Occupation
Do you wish to add another parent/guarantor?*

Family Demographics

Parent/Guardian Information
Parent/Guardian Name:*

First NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
What is your relationship with the patient?*
Copy address from the Parent/Guardian listed above?
Address*

Street Address

Street Address Line 2/APT/Suite

CityState / Province

Postal / Zip Code
Phone Number (cell)*
Email
example@example.com
Employer
Occupation

How did you hear about us?

FriendFamilyGoogleYahooBingSocial Media/Facebook/InstagramSelf referred

Insurance Information

Primary Policy
Do you have insurance?*

YesNo
Subscriber/Policy Holder's Name

First NameLast NameSuffix
D.O.B

MonthDayYear
subscriber/policy holder
Insurance Company Name
Effective date:

MonthDayYear
Date
Policy Number:
Group Number:
Please upload or take a picture of your insurance card.
Please upload a front and back image of your insurance card.

Cancelof
Take a picture of the front and back of your insurance card.
Do you have secondary insurance?

Insurance Information

Secondary Policy
Subscriber/Policy Holder's Name

First NameLast NameSuffix
D.O.B

MonthDayYear
subscriber/policy holder
Insurance Company Name
Effective date:

MonthDayYear
Date
Policy Number:
Group Number:
Please upload or take a picture of your insurance card.
Please upload a front and back image of your insurance card.

Cancelof
Take a picture of the front and back of your insurance card.

Patient Registration
Patient's full name:*

First NameMiddle NameLast NameSuffix
Nickname/Preferred Name:
Date of birth:*

MonthDayYear
Date
Patient sex at birth*
Patient gender identity

MaleFemaleTransgenderNon-binaryI prefer not to sayOther
Primary language spoken*

Patient Registration
Patient's Full Name:*

First NameMiddle NameLast NameSuffix
Nickname/Preferred Name:
Date of Birth:*

MonthDayYear
Date
Patient sex at birth*
Patient gender identity

MaleFemaleTransgenderNon-binaryI prefer not to sayOther
Primary Language Spoken*

Patient Registration
Patient's Full Name:*

First NameMiddle NameLast NameSuffix
Nickname/Preferred Name:
Date of Birth:*

MonthDayYear
Date
Patient sex at birth*
Patient gender identity

MaleFemaleTransgenderNon-binaryI prefer not to sayOther
Primary Language Spoken*

Patient Registration
Patient's Full Name:*

First NameMiddle NameLast NameSuffix
Nickname/Preferred Name:
Date of Birth:*

MonthDayYear
Date
Patient Sex*
Patient gender identity

MaleFemaleTransgenderNon-binaryI prefer not to sayOther
Primary Language Spoken*

Consent for use or Disclosure of Protected Health Information for Payment, Treatment, and Health Care Operations
By signing below, you hereby consent for Piedmont Pediatrics to use and/or disclose information about yourself (or another person for whom you have authority to sign) that is protected under federal law, for the sole purposes of treatment, payment, and health care operations. You may refuse to sign this consent form.

You should read the Notice of Privacy Practices for PHI attached to this form before signing the consent. The terms of the Notice may change from time to time, and you may request a revised copy by asking the Privacy Officer at Piedmont Pediatrics.

You have the right to request that Piedmont Pediatrics restrict how PHI is used or disclosed to carry out treatment, payment, or health care operations. Piedmont Pediatrics is not required to agree to requested restrictions; however, if Piedmont Pediatrics agrees to your requested restriction, the restriction is binding on it.

Information about you is protected under federal law, and you have the right to revoke this consent, unless we have taken action in reliance on your authorization (as determined by our Privacy Officer). By signing below, you recognize that the Protected Health Information used or disclosed pursuant to this Consent may be subject to re-disclosure by the recipient and may no longer be protected under federal law.

I authorize Piedmont Pediatrics, LLC, and medical staff to discuss my healthcare information (which may include history, diagnosis, labs, test results, treatment and other health information) with the contacts listed below. I understand that by leaving spaces blank I am indicating my choice to be a "No Information" and I do not want any information released to anyone else.
You may communicate with the following individuals regarding my child's condition or course of treatment:
Full Name             Full Name

Full Name
Signature of Individual *

Clear
Today's Date:

Informed Consent for Telemedicine Services

By signing this Informed Consent for Telemedicine Services below, I, on behalf of my child, voluntarily request that the Providers participate in my child's medical care through the use of telemedicine. I understand that Providers(i) may participate in a different location than where my child presents for medical care, (ii) may not have the opportunity to perform an in-person physical examination,and (iii) will rely on information provided by me and my child during my telemedicine consultation. I acknowledge that the Provider's advice, recommendations, and/or decisions may be based on factors not within their control, such as incomplete or inaccurate data provided by me or my child or disortions of diagnostic images or specimens that may result from electronic transmissions. I acknowledge that it is my responsobility to provide information about my child's medical history, condition, and care that is complete and accurate to the best of my ability. I understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as to result or cure.

I acknowledge that if the Providers determine that telemedicine services do not adequately address my child's medical needs, such Providers may require an in-person medical evaluation. Also, in the event the telemedicine session is interrupted due to a technological problem or equipment failure, alternative means of communication may be implemented or an in-person medical evaluation may be necessary. If my child experiences an urgent matter, such as a bad reaction to any treatment session, I agree to alert my child's treating physician and in the case of emergencies dial 911 or go to the nearest hospital emergency department immediately.

To faciliate the provision of care and/or treatment through telemedicine, I voluntarily request and authorize the disclosure of all and any part of my child's medical records to the Providers. I understand and agree that the information I am authorizing to be released might include: (i) confidential test results, diagnosis, treatment, and related information: (ii) drug screen results and information about drug and alcohol use and treatment; (iii) mental health information; and (iv) genetic information.

I further understand that the disclosure of my child's medical information to the Providers will be by electronic transmission. Although precautions are taken to protect the confidentiality of this information by preventing unauthorized review, I understand that electronic transmission of data, video images, and audio is new and developing technology and that confidentiality may be compromised by failures of security safeguards or illegal and improper tampering.

I certify that this form has been fully explained to me, that I have read it or have had it read to me, and that I understand its contents.
Signature of Responsible Party:*

Clear
Today's Date:

Insurance Liability Notice
Physician Statement

In many cases, your insurance company will limit payment of service due to limitations of your policy. If your insurance company does not pay for a service due to policy limitation, you are financially responsible for the payment of that service.

Beneficiary Agreement

I understand that in some cases, certain services will be denied payment from my insurance company due to limitations of my personal policy. In the case that my insurance company denies payment for this service, I understand that I am fully responsible for this service.
Signature*

Clear
Today's Date:

Are you interested in lactation or breastfeeding services?

YesNo

Lactation & Breastfeeding Consultation

Release/Consent

A lactation consultation usually includes visual and physical assessment of the mother's breast, visual and physical assessment of the infant's mouth, observation of ther mother and the infant nursing, analysis of the data relating to the breastfeeding situation, demonstration of techniques for improving breastfeeding, and sometimes the use of breastfeeding equipment. I give permission for the lactation consultant to do all of the above.

I understand that payment is due at the time services are rendered. I give permission for information to be released to my insurance company to assist in the evaluation of a claim.
Signature:*

Clear
Today's date:

Financial Policy
Thank you for choosing Piedmont Pediatrics, LLC as your health care provider for your children. We are committed to providing you and your child/children with the highest caliber of care. As part of your relationship with Piedmont Pediatrics, a clear understanding of our financial policies is important so you will know what actions Piedmont Pediatrics will be undertaking on your behalf as well as what your financial responsibilities are to Piedmont Pediatrics. Your health insurance policy is a contract between you and the insurance company. You have certain responsibilities to ensure that proper, accurate and timely submission of charges occurs.

You are required to:
- Present the proper insurance card for your child/children at the time of service. You must bring a valid insurance card to every visit.
- Present a picture ID (driver’s license preferred) for verification of identity, if requested.
- Pay your co-pay at the time of service. As participating providers with your medical insurance plan, our office is required to collect your co-payment on the date of service. If you are unable to pay your co-payment at the time of your appointment the office will charge a $10.00 Administrative surcharge for processing your co-payment after your visit.
- Submit payment and assume responsibility for all charges your health insurance company does not pay for. This includes your co-pay, co-insurance, policy deductibles, and any and all non-covered services and the outstanding balance after your insurance company has submitted payment to Piedmont Pediatrics, LLC.
- Pay your account balance in full within 30 days of receiving Piedmont Pediatrics’ statement of outstanding charges. If your payments are not received in a timely manner and your account is not kept current, your account will be sent to Piedmont Pediatrics Third Party collection agency. Please note you will be responsible for all collection fees. Provided below is a more detailed description of your financial responsibilities.
- You are responsible for knowing the benefits and provisions of your particular insurance plan. If you have any questions regarding your benefits, please contact your carrier prior to your visit in the office.
Fees and Insurance Coverage

We request that you be able to provide valid insurance coverage at every office visit. If we are unable to verify active coverage, any and all fees for your services will be due on the date of service. Insurance claims are filed as a courtesy with the participating plans when there is a valid insurance card provided. You must report any insurance changes to the office as soon as possible. Any information that is inaccurate after the date of service may not be billable to the insurance carrier(in some cases) and may become the responsibility of the account guarantor.

Newborn

When adding a newborn to your insurance plan, please check with your Human Resources department about the requirements of your health plan. Most plans require that newborns be added to the policy within 30 days of birth.

Many insurance policies require prior authorization for tests, including lab and radiology, procedures, specialist referral visits, or hospital admissions. While we try to assist our families with these guidelines, it is the responsibility of the policyholder to know and understand these requirements to avoid costly penalties and denials by your insurance company.

Responsibility for Payment

Even though you have health insurance, you as the guarantor are responsible for payment of all services provided by Piedmont Pediatrics. Piedmont Pediatrics will bill your insurance company, for all services rendered, with the information you have provided us. If your insurance information has changed, please notify us immediately so we may bill the correct insurance carrier.

Co-Payment

Your health insurance policy may state that you must pay a co-payment for all physician visits. This payment is due the day services are rendered to your child/children. Piedmont Pediatrics has a contractual agreement with the health insurance carriers to collect all co-pays on the date the services are rendered.

Remaining balance after your Insurance Company has processed and paid

Once your insurance company has processed your claims, Piedmont Pediatrics will post any payment it receives to your account. If there is a remaining balance, the balance will now be your responsibility. This balance includes your deductible, co-insurance and all non-covered charges. As stated before, we request that you pay your balance in full within 30 days of receiving your statement. We encourage our patients to enroll in our Autopay program for a more convenient and efficient way to pay your remaining balance.

Returned Checks

Piedmont Pediatrics charges a service charge of $35.00 for all returned checks.

Missed Appointment/No Show Visits/Late Cancellations

Missed appointments and late cancelations/rescheduling represent a cost to us, to you, and to other patients who could have been seen in the time set aside for you. We require at least a 24-hour notice for any cancellations or rescheduling of a previously scheduled appointment. Failure to cancel or reschedule your appointment 24 hours in advance will result in a $50.00 administrative fee per appointment. These fees are not covered by your insurance company and are the sole responsibility of the guarantor on the account.

Saturday office hours

Piedmont Pediatrics operates on Saturdays for urgent care/sick children only. Piedmont Pediatrics charges an additional fee for Saturday services. This fee may or may not be covered by your insurance carrier.

Medical Records

Requests for medical records require a signed Medical Release Form stating the authorization of the release from Piedmont Pediatrics to either the parent or current physician's office. Piedmont Pediatrics will release one (1) copy of standard medical records at no charge. After the first copy, there will be a charge in accordance with the guidelines set forth by the State of Georgia for copying medical records.

If you are transferring from another pediatrician, we request that you have those medical records transferred to our office before services are rendered here.

I have read the above financial policies for Piedmont Pediatrics, LLC and I agree to the terms listed above.

Annual Administrative Fee

(AAF)
Piedmont Pediatrics is committed to providing you with exceptional care. As you know, many changes have taken place in the healthcare industry. Amongst these changes is the rise in administrative costs of operating a doctor's office. Services that were once covered by insurance are now either partially covered, covered under certain medical necessities or not covered at all. We want to continue to provide the highest quality of medical care to our families, but unfortunately, this includes providing services that are no longer covered by your insurance company. Over the past several years, Piedmont Pediatrics has absorbed the cost of these non-covered services. In the current environment, this has become unsustainable.

After much consideration, Piedmont Pediatrics finds it necessary to charge an Annual Administrative Fee (AAF) of $20.00 per patient with a maximum of $50.00 per family with three or more children. This fee is intended to help cover services such as maintaining medical records, prior authorizations, completion of immunization records, school forms, sports forms, FMLA forms, daycare forms, insurance filings and applications, email correspondences, etc. Your insurance company will not cover the annual administrative fee or any of these services. Your out-of-pocket expenses will be lower by charging an annual administrative fee than charging you for individual services.

All patients that are up to date with their annual administrative fees will allow our staff to provide you with consistent, efficient, and timely patient correspondence, medical record maintenance, and completion of forms throughout the year. You may speak with a receptionist to pay your Annual Administrative FEE (AAF).

AutoPay Policy

Credit Card on File
We are committed to providing you with exceptional care, as well as making our billing processes as simple and efficient as possible. As you may be aware, the current healthcare market has resulted in insurance policies increasingly transferring costs to you, the insured. This is driving many practices to adopt new policies to enable more efficient operational processes. Some insurance plans require deductibles and copayments in amounts not known to you or us at the time of your visit.

To streamline our billing and payment system and to provide a seamless, convenient way for patients to pay their bills, Piedmont Pediatrics now offer an AutoPay option for all patients to keep an active credit card on file with us. Similar to the hotel payment models, you are asked to swipe a credit card number at the time you check in and the information will be held securely until your insurance provider has paid their portion for the services rendered and notified us of the amount your policy determines falls to patient responsibility.

The Process

Once your insurance has processed your claims, they will send an Explanation of Benefit (EOB) to both you and our office showing the amount of your total patient responsibility. You will typically receive the EOB before we do, if you disagree with the patient responsibility balance owed, it is your responsibility to contact your insurance carrier immediately.

When we receive the EOB, we will enter all pertinent payment information into our system. You will then receive an email notifying you of your patient responsibilty portion. Your credit card will be charged, typically within 24-48 hours of receiving the email. After your card is charged, you will receive a second email containing a copy of the receipt.

Charges

Your card on file will be charged for the following:
- Visit payments not collected from you at the beginning of your visits such as copayments, co-insurance, and deductibles
- Non-covered services and/or denial of coverage by your insurance company
- No show or late cancellation charges
- Self-pay payments
- Outstanding balances
If the credit card on file for you changes, please notify our billing team immediately. You are welcome to leave an HSA (Health Savings Account) or Flex Plan Card on File. You may also pay for your visits with cash or a personal check at the time services are rendered.

Should you decline to participate in the Autopay option, a billing fee of $5.00 will be added to your account for any balances we must attempt to collect through mailing a traditional monthly statement.

If there is a problem with your bill/claim and it is brought to our attention after your card payment processes, we will investigate it and if we owe you any money, we will refund it to the same card within 5 business days of resolution of the issue.

This in no way will compromise your ability to dispute a charge or question the insurance company's determination of payment. You will be given time to contact our office and speak with one of our billing experts to discuss your charges before we process your credit card on file.

To finalize your registration, we will need a copy of your child's medical records. We recommend having a copy of your medical records on file before your first appointment. To start the process of releasing your records to Piedmont Pediatrics you can choose one of the three options:
1. Contact your child's previous doctor and ask if they have authorization documents for you to fill out. Request your medical records in a hard copy or digital file. Have the previous doctor send your records directly to Piedmont Pediatrics.
2. If you have access to a patient portal, you may be able download your medical records directly from the portal. This could save a lot of time.
3. Recommended. Piedmont Pediatrics can send your medical records release request to the previous doctor on your behalf. This is the best option to ensure that your records are sent to our office in time for your first appointment.
To continue, choose one of the following:*

I authorize Piedmont Pediatrics to send my records release request to my previous physician.I do not need authorization for previous medical records.

Medical Records Release Authorization
I herby request the release health records of:

Patient Name(s) and Date of Birth:

{patientsFull} {dateOf210}

{patientsFull208} {dateOf43}

{patientsFull274} {dateOf276}

{patientsFull298} {dateOf300}
Healthcare provider or practice Piedmont Pediatrics is requesting records from:
Practice/Provider Name:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone#:*
Please enter a valid phone number.
Fax #:
Please enter a valid phone number.
Medical Information to be disclosed*
Signature*

Clear
Today's date:
I herby request the release of medical records to:

Piedmont Pediatrics, LLC

105 Collier Road N.W. Suite 4060

Atlanta, Georgia 30309

PH: 404.351.6662 || Fx: 404-793-0477 || medical.records@piedmontpediatrics.org

Click submit if you are ready to submit your registration form. You may click the back button to go back and make changes to your form. Click print if you would like to print a PDF copy of your registration.
Please verify that you are human*
Should be Empty:

New Patient Registration

Family Demographics

Family Demographics

Insurance Information

Please upload or take a picture of your insurance card.

Insurance Information

Please upload or take a picture of your insurance card.

Family Medical History

Patient Registration

Patient Birth History

Patient Medical History

Patient Registration

Patient Birth History

Patient Medical History

Patient Registration

Patient Birth History

Patient Medical History

Patient Registration

Patient Birth History

Patient Medical History

Electronic Communication Consent Form

Please confirm the following:

Consent for use or Disclosure of Protected Health Information for Payment, Treatment, and Health Care Operations

Informed Consent for Telemedicine Services

Insurance Liability Notice

Lactation & Breastfeeding Consultation

Release/Consent

Financial Policy

Fees and Insurance Coverage

Newborn

Responsibility for Payment

Co-Payment

Remaining balance after your Insurance Company has processed and paid

Missed Appointment/No Show Visits/Late Cancellations

Saturday office hours

Medical Records

I have read the above financial policies for Piedmont Pediatrics, LLC and I agree to the terms listed above.

Annual Administrative Fee

AutoPay Policy

The Process

Charges

Medical Records Release Authorization

Healthcare provider or practice Piedmont Pediatrics is requesting records from: