Thank you for your interest in establishing care with Piedmont Pediatrics!

This registration paperwork will allow you to provide proper demographics, insurance information, and health history for your children; as well as review all practice policies and administrative fees.

Please have your insurance information handy to complete this paperwork.

**Excluded Insurance Plans**
We participate in most insurance plans, with the exception of the providers listed below. This list is subject to change without notice. We still recommend reaching out to your insurance carrier directly to confirm if Piedmont Pediatrics and our providers are in-network with your specific plan(s).
Aetna Select HMO
Aetna Whole Health
Ambetter
Amerigroup
BCBS Blue Value Individual HMO Plans through the Market Place (Exchange)
Caresource
Cigna + Oscar
Kaiser HMO plans (We do accept Kaiser through PHCS)
Oscar
Medicaid/Medicare
Peachstate/Peachcare
Wellcare

Families also have the option to self-pay for services rendered within the practice if valid insurance is not applicable.

Self-pay visit payments are due at the time of service.

I consent that Piedmont Pediatrics, LLC can provide their services and communicate with me via mobile phone, messages, e-mail and any kind of online communications, provided that these communuications comply with privacy regulations.

I understand that Piedmont Pediatrics can reach me any time to remind me of my appointments or let me know in case of any changes about my appointments. I understand that Piedmont Pediatrics can employ and use a third-party automated system to contact me for the purpose of "confirm", "reschedule" or "cancel" appointments, reminders and notifications for patient balances, statements and receipts.

 

I agree to allow Piedmont Pediatrics, LLC to contact me in the following methods regarding my private health information, evaluation, and treatment. I authorize Piedmont Pediatrics, LLC to leave messages for me when I am unavailble.

Please confirm the following:

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.

 

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.

 

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.

Chaperone Policy

Purpose:
The purpose of this policy is to outline the protocol for the use of chaperones during patient examinations and procedures to ensure patient comfort, privacy, and safety, and to protect the rights of both patients and healthcare providers.

Scope:
This policy applies to all physicians, nurse practitioners, physician assistants, medical staff, and patients in the office.

Policy Statement:

In accordance with best practices and ethical guidelines, a chaperone will be provided during a patient’s physical exam, specifically the part of the exam that involves intimate areas (i.e. genital or breast exam). The presence of a chaperone can provide an additional layer of comfort and assurance to both the patient and the healthcare provider.

Definitions:

Chaperone: A staff member or a trained individual present during patient examinations or procedures to ensure privacy, provide comfort, and prevent misunderstandings. A chaperone may be a medical assistant, nurse, or another staff member depending on the circumstances and the patient’s preference.
Intimate Exam: Any examination that involves the patient's private areas (i.e. genital or breast examination). 

Procedure:

1. Offer of a Chaperone:
   Patients will be informed that a chaperone will be present during any physical examination or procedure that involves intimate areas.
   The patient will be notified verbally of the chaperone’s presence, prior to the start of the examination. It will be clearly explained that the chaperone is available to ensure comfort and privacy.
   The presence of the chaperone will be documented in the patient chart.
2. Patient Preferences:
   The patient or patient’s parent/guardian may decline the presence of the chaperone.
   If a specific gender is requested for the chaperone, reasonable efforts will be made to accommodate this request, provided that appropriate staff is available.
   If the patient or patient’s parent/guardian declines the chaperone, the healthcare provider will respect their wishes and continue with the examination. However, the patient will be informed of the option to request a chaperone at any point during the procedure.
3. Role of the Chaperone:
   The chaperone’s role is to observe the exam/procedure and ensure the patient’s comfort and safety.
   The chaperone will maintain confidentiality regarding the examination and any information shared during the encounter. All chaperones are trained to respect privacy and confidentiality.
4. Examination Without a Chaperone:
   If a patient/patient’s parent/guardian declines a chaperone, the healthcare provider may proceed with the examination but must document the decision in the medical record.
   The physician or healthcare provider may also decline to perform the examination or procedure if they feel uncomfortable proceeding without a chaperone, and this will be discussed with the patient.
5. Emergency Situations:
   In emergency situations where a chaperone cannot be present, the healthcare provider will act in the best interest of the patient, while still maintaining respect for the patient’s dignity and privacy.

 

Documentation

• The presence of a chaperone will be documented in the patient’s medical record, including whether the patient accepted or declined the offer of a chaperone.
• The name of the chaperone present during the examination will be recorded.

Non-Compliance 

Failure to offer a chaperone or to respect a patient’s preferences regarding a chaperone may lead to an internal review of the situation and appropriate action in line with the practice’s standards.

Review and Updates 

This policy will be reviewed annually and updated as needed to comply with current regulations, best practices, and patient feedback.

Use of Artificial Intelligence (AI) Scribe During Medical Encounters Patient Authorization

Facts about an Al Scribe

Our medical office is using a new AI scribe technology. This tool helps us during patient medical encounters by making clinical notes or other records based on our talks with patients. The Al tool does not interact with you. It listens to and records the conversations and makes a draft clinical note. Your doctor will then review, edit, and finalize the clinical note. Using this tool lets us focus more on you, the patient, and less on computer records.

Risks and Common Problems

There are risks linked to the use of AI, which include but are not limited to:

Language capabilities: AI scribe technology right now works only with English-speaking patients. There may be some errors in translation for those with limited English skills.

Breakdown of the AI tool: This could stop or slow your evaluation or treatment.

Security safeguards: If there is a breakdown in the tool's security safeguards, this could result in your health data being made available to other people.

Other Choices

Your participation is fully your choice. If you do not agree to the use of this Al tool during your visit, it will not be used. If you change your mind about the use of this tool in the future, you may withdraw at any time by telling your doctor and we will not use the AI tool at or after that visit unless you later decide you wish to use the tool.

I confirm by signing below that:

• I have been able to ask questions about the use of AI during my medical encounters.
• No guarantees have been made about the use of AI.
• All of my questions have been answered.
• I agree to the use of the AI tool based on the terms noted above.

 

RECORDING OFFICE VISITS

-PRACTICE POLICY-

With the proliferation of smart phones, smart glasses (e.g., Meta glasses), tablets, micro recorders, and other video and audio recording devices which capture and store video and audio files (collectively, "Recorders"), we wanted to make you aware of our office policy on the use of these Recorders within our practice and during your visit with a provider, either in person or via telehealth (our "Recording Policy"). Please ask the provider or any staff member if you ever have any questions about our Recording Policy.

Please understand that the genesis of our Recording Policy is to protect your personal health information, and that of other patients, from being accessed by non-authorized parties. As a medical provider, we are subject to certain state and federal privacy laws, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which require us to take reasonable measures to prevent the unauthorized access of our patients' protected health information (PHI). Recorders used during an office visit may result in the unauthorized recording of another patient's PHI, intentionally or inadvertently, or you may misplace or lose your Recorder once you leave the office, providing others with access to your PHI and potentially subjecting us to fines and penalties.

Therefore, we have developed the following Recording Policy, and we ask that you carefully read and sign where indicated to signify your (i) understanding of the Recording Policy, and (i) agreement to adhere to same.

1. While in the office lobby, administration areas, receptionist area, billing office, hallways, and other common areas (collectively, the "Common Areas"):

The use of all Recorders is strictly prohibited in the Common Areas unless (1) the Recorder is needed for communication purposes in accordance with the Americans with Disabilities Act (ADA) or other state/federal access to healthcare laws (collectively, "Access Laws"), OR (2) the Recorder is needed to help you or your child remember what a staff member said about billing questions, follow up instructions, future appointments, etc. If the latter, we ask that the patient/parent first ask the staff member for permission to record the interaction. Under no circumstances, however, is a patient/parent permitted to video record in the Common Areas unless authorized by Access Laws.

2. While in a patient room communicating with a provider (the "Patient Room"):

The use of all Recorders is strictly prohibited in the Patient Room unless (1) the Recorder is needed for communication purposes in accordance with Access Laws, OR (2) the Recorder is needed to help the patient or parent remember what the provider told him/her at the time of the visit. If the latter, we ask that the patient/parent first ask the provider for permission to record the interaction. Under no circumstances, however, is a patient/parent permitted to video record a provider visit unless authorized by Access Laws.

3. While on a telehealth visit (the "Telemedicine Exam"):

The subsequent posting of a recorded visit or Telemedicine Exam on any public social media platform, including but not limited to, YouTube, Facebook, Instagram, and Snapchat, is strictly prohibited.

If a provider or staff member has a reasonable belief that a patient or parent has violated this Recording Policy, the patient or parent will be (i) asked to turn the Recorder off, (ii) reminded of the Recording Policy, (ili) asked to delete any dio/video recordings taken within the Common Areas or Patient Room, (iv) asked to remove/take-down a social media posting of any visit, if applicable, and (v) potentially, terminated from the practice.

By signing below, I am confirming that I have been able to ask questions about the Recording Policy, that all of my questions (if any) have been answered, and I agree to abide by the Recording Policy.

 

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.

 

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-- including appointments for wellness checks, lactation services, nutrition services, and allergy related appointments.  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.

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).

To finalize your registration, we will need a copy of your child's medical records prior to their first appointment. 

If the patient is a newborn and has not been seen by another healthcare provider, then we will need your newborn's discharge paperwork from their discharging ogranization (hospital, birthing center, or intensive care unit). 

If it is an older patient, Piedmont Pediatrics requires immunizations, growth charts, and the most recent wellness visit before we can schedule a new patient.

To start the process of releasing your records to Piedmont Pediatrics you can choose one of the three options:

1. If you already have a copy of your child's medical records, you can upload them directly to your new patient registration paperwork. (If your previous provider has a patient portal, you can usually pull these records from there.)*Recommomended

2. Contact your child's previous provider and ask if they have authorization documents for you to fill out. Have the previous doctor send your records directly to Piedmont Pediatrics. 

3. Piedmont Pediatrics can send your medical records release request to the previous doctor on your behalf.   

I hereby request the release health records of:

Patient Name(s) and Date of Birth:

{patientsFull}                                    {dateOf210}

{patientsFull208}                              {dateOf43}

{patientsFull274}                              {dateOf276}

{patientsFull298}                              {dateOf300}

 

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

 Fax is the best retrieval method for records.