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  • New Patient Registration

    Piedmont Pediatrics|105 Collier RD. NW Ste. 4060 Atlanta, GA 30309 404-351-6662 | www.piedmontpediatrics.org

  •  
      {form_title}
     
    Primary Parent/Caregiver Legal Name: {primaryParentcaregiver}
    Date of Birth {dateOf}
    What is your relationship with the patient? {whatIs184}
    Home Address {homeAddress}
    Phone Number (cell) {phoneNumber186}
    Email {email187}
    Employer {employer188}
    Occupation {occupation189}
    Do you wish to add another parent/guarantor? {doYou179}
    Parent/Guardian Name: {parentguardianName182}
    Date of Birth {dateOf183}
    What is your relationship with the patient? {whatIs}
    Copy address from the Parent/Guardian listed above? {copyAddress}
    Address {address}
      {phoneNumber}
    Email {email}
    Employer {employer}
    Occupation {occupation}
    How did you hear about us? {howDid}
    Do you have an active insurance policy? {doYou519}
    Subscriber/Policy Holder's Name {subscriberpolicyHolders}
    D.O.B {dob}
    Insurance Company Name {insuranceCompany}
    Effective date: {effectiveDate}
    Policy Number: {policyNumber}
    Group Number: {typeA495}
    Please upload a front and back image of your insurance card. {pleaseUpload}
    Take a picture of the front and back of your insurance card. {typeA444}
    Do you have secondary insurance? {doYou}
    Subscriber/Policy Holder's Name {subscriberpolicyHolders193}
    D.O.B {dob194}
    Insurance Company Name {insuranceCompany195}
    Effective date: {effectiveDate198}
    Policy Number: {policyNumber496}
    Group Number: {typeA497}
    Please upload a front and back image of your insurance card. {pleaseUpload199}
    Take a picture of the front and back of your insurance card. {takeA}
    Has a family member ever been diagnosed with any of the following? Please check all that apply. {hasA}
    Please list the relationship of the family member for each specific diagnosis checked above. {pleaseList269}
    How many children do you need to register? {howMany}
    Patient's full name: {patientsFull}
    Nickname/Preferred Name: {nicknamepreferredName209}
    Date of birth: {dateOf210}
    Patient sex at birth {patientSex211}
    Patient gender identity {patientGender}
    Primary language spoken {primaryLanguage212}
    What is the name of the hospital where the patient was born? {whatIs49}
    Was this child? {wasThis}
    If adopted, at what age? {ifAdopted}
    Type of delivery {typeOf}
    Birth weight: {typeA160}
    Birth Length: {birthLength}
    Did any of the following complications apply at the time of birth? {didAny}
      {hasiencedAny}
    Additional Medical History/Symptoms {additionalMedical}
    List any surgeries/hospitalizations. {listAny}
    List any known allergies. {listAny59}
    Is the patient currently taking any medications? {isThe}
    Please list all prescribed and over-the-counter medications (incl doses). {pleaseList}
    Patient's Full Name: {patientsFull208}
    Nickname/Preferred Name: {nicknamepreferredName}
    Date of Birth: {dateOf43}
    Patient sex at birth {patientSex}
    Patient gender identity {patientGender506}
    Primary Language Spoken {primaryLanguage}
    What is the name of the hospital where the patient was born? {whatIs251}
    Was this child? {wasThis252}
    If adopted, at what age? {ifAdopted253}
    Type of delivery {typeOf254}
    Birth weight: {birthWeight255}
    Birth Length: {birthLength256}
    Did any of the following complications apply at the time of birth? {didAny511}
    Please check all that apply. {pleaseCheck515}
    Additional Medical History/Symptoms {additionalMedical262}
    List any surgeries/hospitalizations. {listAny263}
    List any known allergies {listAny264}
    Is the patient currently taking any medications? {isThe265}
    Please list all prescribed and over-the-counter medications. {pleaseList266}
    Patient's Full Name: {patientsFull274}
    Nickname/Preferred Name: {nicknamepreferredName275}
    Date of Birth: {dateOf276}
    Patient sex at birth {patientSex277}
    Patient gender identity {patientGender507}
    Primary Language Spoken {primaryLanguage278}
    What is the name of the hospital where the patient was born? {whatIs281}
    Was this child? {wasThis282}
    If adopted, at what age? {ifAdopted283}
    Type of delivery {typeOf284}
    Birth weight: {birthWeight}
    Birth Length: {birthLength286}
    Did any of the following complications apply at the time of birth? {didAny512}
    Please check all that apply. {pleaseCheck}
    Additional Medical History/Symptoms {additionalMedical290}
    List any surgeries/hospitalizations. {listAny291}
    List any known allergies {listAny292}
    Is the patient currently taking any medications? {isThe293}
    Please list all prescribed and over-the-counter medications. {pleaseList294}
    Patient's Full Name: {patientsFull298}
    Nickname/Preferred Name: {nicknamepreferredName299}
    Date of Birth: {dateOf300}
    Patient Sex {patientSex301}
    Patient gender identity {patientGender508}
    Primary Language Spoken {primaryLanguage302}
    What is the name of the hospital where the patient was born? {whatIs305}
    Was this child? {wasThis306}
    If adopted, at what age? {ifAdopted307}
    Type of delivery {typeOf308}
    Birth weight: {birthWeight309}
    Birth Length: {birthLength310}
    Did any of the following complications apply at the time of birth? {didAny513}
    Please check all that apply. {pleaseCheck517}
    Additional Medical History/Symptoms {additionalMedical314}
    List any surgeries/hospitalizations. {listAny315}
    List any known allergies {listAny316}
    Is the patient currently taking any medications? {isThe317}
    Please list all prescribed and over-the-counter medications. {pleaseList318}
    I consent to the use of mobile phone communications. {iConsent}
    I consent to the use of texting (messages) communications. {iConsent374}
    I consent to receive electronic notifications for confirming, rescheduling, or cancelling my appointments. {iConsent376}
    I consent to receive electronic billing notifications. {iConsent375}
    Would you like to subscribe to our newsletter and receive updates, announcements, events, and other important notifications? {wouldYou}
    Please provide an email address to receive our newsletters? {pleaseProvide}
    Would you like to add another email address? {wouldYou382}
    Please provide an email address to receive our newsletters? {pleaseProvide381}
      {input483}
    You may communicate with the following individuals regarding my child's condition or course of treatment: {youMay}
    Today's Date: {typeA462}
    Signature of Responsible Party: {signatureOf}
    Today's Date: {typeA470}
    Signature {signature}
    Today's Date: {typeA463}
    Are you interested in lactation or breastfeeding services? {areYou}
    Today's date: {typeA464}
    Terms and Conditions {typeA163}
    Terms and Conditions {typeA165}
    Signature {signature570}
    To continue, choose one of the following: {toContinue}
    Medical Records Submission Box {submissionBox}
    Practice/Provider Name: {practiceproviderName}
    Address {address427}
    Provider Phone #: {providerPhone}
    Protected Health Information to be disclosed: {protectedHealth}
    Provider Fax #: {providerFax}
    Signature {signature466}
    Today's date: {typeA467}
    		 
         
     
    You can {edit_submission} and {all_submissions} easily.
     

  • Family Demographics

    Primary Parent/Caregiver Information
  •  / /

  • Family Demographics

    Secondary Parent/Guardian Information
  •  / /
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  • Insurance Information

    Please have your policy information and insurance card readily available for this next section.

  • **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. These monetary fees are due at the time of service.

  • Insurance Information

    Primary Policy
  •  - -
  •  - -

  • Please upload or take a picture of your insurance card.

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  • Insurance Information

    Secondary Policy
  •  - -
  •  - -

  • Please upload or take a picture of your insurance card.

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  • Family Medical History

    Family Medical History

  • Patient Registration

    Patient Registration

    Patient/Child Number One
  •  - -

  • Patient Birth History

    Please complete each question to the best of your knowledge.

  • Patient Medical History

    Has the patient experienced any of the following medical complications?
  • Patient Registration

    Patient Registration

    Patient/Child Number Two
  •  - -

  • Patient Birth History

    Please complete each question to the best of your knowledge.

  • Patient Medical History

    Has the patient experienced any of the following medical complications?
  • Patient Registration

    Patient Registration

    Patient/Child Number Three
  •  - -

  • Patient Birth History

    Please complete each question to the best of your knowledge.

  • Patient Medical History

    Has the patient experienced any of the following medical complications?
  • Patient Registration

    Patient Registration

    Patient/Child Number Four
  •  - -

  • Patient Birth History

    Please complete each question to the best of your knowledge.

  • Patient Medical History

    Has the patient experienced any of the following medical complications?
  • Electronic Communication Consent Form

    Electronic Communication Consent Form

  • 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:

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

    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:
       

  • Clear

  • 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.

     

  • Clear
  • Insurance Liability Notice

    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.

  • Clear

  • 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.

     

  • Clear
  • Financial Policy

    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

    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).

  • Clear
  • Medical Records

    Medical Records

    (Protected Health Information)

  • 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.   

  • Medical Records Submission Box

    If you already have an electronic copy of your children's medical records, please utilize this submission box to upload them. Newborn parents--- feel free to upload your discharge paperwork here as well.
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  • Medical Records Release Authorization

    Medical Records Release Authorization

  • I hereby 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:

  • Clear

  • 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.

     

     

  • 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.

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