New Patient History FORM #: PEDS 110...correo de voz, correo electrónico o personas no autorizadas que no figuran en el formulario de consentimiento para tratar. Si prefiere que dejemos

New Patient History FORM #: PEDS 110

Name: _______________________________ Date of Birth: ____________________ Today’s Date________________

BIRTH HISTORY

Was your child born Full-term or Preterm? _______________ If Pre-term, how many weeks gestation?______

Were there any complications during birth or in the nursery? ___________________________________________

Birth Weight ___ lb. ___oz. Hospital __________________ City_____________ State ______

Type of Delivery: □ Vaginal □ C-section Hearing Screen: □ Passed □ Failed Males Circumcised □ Yes □ No

CHILD’S HISTORY

Do you consider your child to be in good health? □ Yes □ No □ Unsure Explain:________________________________

Does your child have any serious illnesses or □ Yes □ No □ Unsure Explain:________________________________

medical conditions?

Has your child had any surgeries? □ Yes □ No □ Unsure Explain:________________________________

Has your child ever been hospitalized? □ Yes □ No □ Unsure Explain:________________________________

Is your child allergic to any medications or food? □ Yes □ No □ Unsure Explain:________________________________

Please list any medications your child is currently taking: ____________________________________________________

Are your child’s immunizations up to date? □ Yes □ No □ Unsure Explain:________________________________

Please list any place your child has had vaccines: __________________________________________________________

FAMILY HISTORY

Have any family members (parents, grandparents, siblings, aunts and uncles of your child) had the following?

Hypertension □ Yes □ No Diabetes □ Yes □ No Heart disease □ Yes □ No

Cancer □ Yes □ No Asthma □ Yes □ No Allergies □ Yes □ No

Eczema □ Yes □ No Anemia □ Yes □ No Seizures □ Yes □ No

Liver Disease □ Yes □ No Kidney disease □ Yes □ No Substance abuse□ Yes □ No

HIV/AIDS □ Yes □ No Heart Attack (before the age of 55 years old) □ Yes □ No

If you answered yes to any of the above, or there is an additional problem not listed, please explain:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Historial de Nuevo Paciente FORM #: PEDS 110

Nombre del Paciente: __________________________ Fecha de Nacimiento: ________ Fecha de hoy_________

Historial del Nacimiento

Embarazo completo de 9 meses o prematuro? _______________ Si prematuro a las cuantas semanas?______

El nino tuvo algun problema de recien nacido? ___________________________________________

Peso de nacimiento ___ lb. ___oz. En que hospital __________________ Ciudad_____________ Estado ______

Tipo de entrega: □ Vaginal □ Cesarea Examen de audio: □ Pasado □ Fracasado

Niños circumcision □ Si □ No

Historial de Nino/a

Su nino esta en buena salud? □ Si □ No □ No se Explicar:________________________________

Tiene su hijo alguna enfermedad grave o □ Si □ No □ No se Explicar:________________________________

condicion medicas?

Ha tiendo su hijo alguna cirugia? □ Si □ No □ No se Explicar:_________________________________

Su hijo ha sido hospitalizado? □ Si □ No □ No se Explicar:_________________________________

Alergias a los medicamentos o alimentos? □ Si □ No □ No se Explicar:__________________________________

Por favor escribe cualquier medicamento que su hijo este tomando: ________________________________________

Vacunas estan al corriente? □ Si □ No □ No se Explicar:__________________________________

Por favor indique los lugares donde se han recivido vacunas: _____________________________________________

Historial de Familia

Algún familiar (padres, abuelos, hermanos, tias o tios) de tu nino/a an tiendo lo siguiente?

hipertensiòn □ Si □ No diabetes □ Si □ No enfermedad corazòn □ Si □ No

cancer □ Si □ No asma □ Si □ No alergias □ Si □ No

eczema □ Si □ No anemia □ Si □ No convulsiones □ Si □ No

enfermedad hepatica □ Si □ No HIV/AIDS □ Si □ No abuso de sustancias □ Si □ No

enfermedad renal □ Si □ No Ataques al Corazon antes de la edad de 55 anos □ Si □ No

Si ha respondido si a las preguntas anteriores o hay un problema adicional que no este en las lista, explique:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Patient Information Sheet FORM #: PEDS 111

PATIENT (CHILD) INFORMATION

Name

Address

City, State, Zip

Phone ( ) County

Birthdate Sex □ Male □ Female

Ethnicity □ Hispanic or Latino □ Not Hispanic or Latino □ Unknown

Race □ White □ Black □ Hawaiian Native □ Asian □ Unknown

PARENTAL/GUARDIAN BILLING INFORMATION

MOTHER’S INFORMATION

FATHER’S INFORMATION

LEGAL GUARDIAN’S INFORMATION

Name Address City, State, Zip Primary Phone Cell Phone Social Security # Date of Birth Employer Occupation Work Phone Email Address

Guarantor’s Primary language: □ English □ Spanish □ Other_________________________

With whom does the patient reside? □ Both parents □ Mother □ Father □ Legal Guardian

□Other _________________________

PLEASE LIST ALL SIBLINGS THAT COME TO THIS PRACTICE

Name ________________________________ Birthdate_______ Name__________________________ Birthdate____________

Name_________________________________ Birthdate_______ Name__________________________Birthdate____________

EMERGENCY CONTACT INFORMATION

Name (someone who can be contacted if we cannot reach a parent/guardian) Phone Relationship to Patient

I hereby authorize Peds Care, P.C., its physicians and staff, to render appropriate medical care to my dependent child listed above.

Parent/Guardian: _____________________________________________ Date ______________________________________________________

Hoja De Informacion Del Paciente FORM #: PEDS 111

Informacion Del Paciente (Niño, Niña)

Nombre del Niño(A)

Direccion

Ciudad, Estado, Zip Code

Telefono Condado

Fecha de Nacimiento: □ Masculino □ Femenino

Ethnicity □ Hispano or Latino □ No Hispano o Latino □ No Sabe

Raza □ Blanco □ Asiatico □ Negro □ Nativo de Hawai □ No Sabe

INFORACION DE PERSONA RESPONSIBLE A LA FACTURA

INFORMACION DE MADRE

INFORMACION DE PADRE

INFORMACION DE GUARDIAN

Nombre Direccion Ciudad, Estado, Zip Code Telefono de Casa Telefono de Cellular De Segruro Social Fecha de Nacimiento Empleador Ocupacion Telefono de Trabajo Correo Electronico

Lenguaje de preferencia de garante: □ Espanol □ Ingles □ Otro_________________________

Con quien vive el paciente? □ Ambos el padre, la madre □ Solo la madre □ Solo el padre □ El tutor legal

□ Otro _________________________

Por Favor hacer una lista de todo el hermano quien venir a este oficina

Nombre ______________________ Fecha de nacimiento__________ Nombre__________________ Fecha de nacimiento______

Nombre ______________________ Fecha de nacimiento__________ Nombre__________________ Fecha de nacimiento______

CONTACTO EN CASO DE EMERGENCIA

Por favor poner algun amigo o familiar que pueda responder por usted en caso de no poder ubicarsele

Nombre: Telefono: La Relacion a la paciente:

Yo autorizo a Peds Care, P.C., sus doctors y personal de esta oficina a que apliquen el apropiado cuidado a mi hijo(a) quien es depediente de mi.

Firma de padre/madre/guardian _____________________________________________ Fecha _________________________________________

Patient Insurance Information FORM #: PEDS 112

If you are not the parent/legal guardian please do not sign and see a person at our front desk

Child’s Name__________________________________ Date of Birth_________________

What kind of insurance does your child currently have?

□ No insurance or Self Pay □Applied for Medicaid or Peachcare

□ Medicaid □ Amerigroup □Wellcare □Peachstate □ Caresource

□ Peachcare □ Amerigroup □Wellcare □Peachstate □ Caresource

□ Private □ Other__________________________________________

What provider is listed on the patient’s card? _____________________________

Please present Medicaid or Peachcare Care at every visit

Private Insurance Information

Primary Secondary

Insurance Company_________________________ Insurance Company______________________

Insured (Employee)_________________________ Insured (Employee)______________________

Birthdate________________ SSN______________ Birthdate_____________ SSN______________

Relationship to patient_______________________ Relationship to patient____________________

Employer_______________ Group#____________ Employer________________Group#_________

ID#_________________ Effective Date__________ ID#______________ Effective Date___________

Important Information

Please initial that you have read the following

___ Preventive Care Plus Problem Oriented: if your child is here for a preventive care visit, and have significant new symptoms or

worsening of an existing problem, your provider may be able to address both at today’s visit (time permitting). Your insurance will

be billed both a preventive care code and an evaluation and management (E&M) code. In some cases, insurance companies will not

pay for both visits provided by the same provider on the same day. You are responsible for any copayment or payment for any

services denied by your insurance company unless specifically addressed in a participating provider contract with the insurance.

___ I authorize Peds Care, P.C. to release to my insurance company or its agents any information needed to process insurance claims

and/or determine benefits payable for related services. I request that payment of insurance benefits be made on behalf of my

dependent to Peds Care, P.C. for any services furnished to the dependent provider.

____________________________________________________________________________________________________________

Signed Date Relationship to Patient

Información del seguro del paciente FORM #: PEDS 112

Si usted no es el padre / tutor legal, por favor no firme y vea a una persona en nuestra recepción

Nombre__________________________________ Fecha de Nacimiento_________________

Qué tipo de seguro tiene actualmente su hijo?

□ Sin seguro ni autopago □ Medicaid solicitado or Peachcare

□ Medicaid □ Amerigroup □Wellcare □Peachstate □ Caresource

□ Peachcare □ Amerigroup □Wellcare □Peachstate □ Caresource

□ aseguranza privada □ Otro__________________________________________

Qué proveedor esta en la tarjeta del paciente?_____________________________

Presente Medicaid o Peachcare Care en cada visita

Información de seguro privado

Primary Secondary

Insurance Company_________________________ Insurance Company______________________

Insured (Employee)_________________________ insured (Employee)______________________

Birthdate________________ SSN______________ Birthdate_____________ SSN______________

Relationship to patient_______________________ Relationship to patient____________________

Employer_______________ Group#____________ Employer________________Group#_________

ID#_________________ Effective Date__________ ID#______________ Effective Date___________

Información importante

Por favor escribe iniciales que ha leído lo siguiente

___ Atención cuidado preventivo y orientador del problema : si su hijo está aquí para una visita de atención preventiva

y tiene nuevos síntomas significativos o empeoramiento de un problema existente, su proveedor podrá abordar ambos

en la visita de hoy (si el tiempo lo permite). Su seguro recibirá un código de atención preventiva y un código de

evaluación y gestión (E & M). En algunos casos, las compañías de seguros no pagarán las dos visitas provistas por el

mismo proveedor el mismo día. Usted es responsable de cualquier copago o pago por cualquier servicio denegado por

su compañía de seguros a menos que se trate específicamente en un contrato de proveedor participante con el seguro.

___ Yo Autorizo a Peds Care, P.C. a compartir a mi compañía de aseguranza o a sus agentes toda la información

necesaria para procesar los reclamos de seguro y / o determinar los beneficios pagaderos por los servicios relacionados.

Solicito que el pago de los beneficios del seguro se realice en nombre de mi dependiente a Peds Care, P.C. para cualquier

servicio proporcionado al proveedor dependiente.

_____________________________________________________________________________________

Firma Fecha Relación con el paciente

Consent to Treat FORM #: PEDS 113

Please be advised that only a parent or legal guardian should complete this form. If you are not the

parent/legal guardian, please leave this form blank. Thank you.

Child’s Name: _______________________________ Birthdate ______________

Please list any individuals below that have your consent to authorize medical treatment, approve vaccines, pick up

prescriptions, speak to staff over the phone in regards to your child, or anything else deemed necessary by the health

care provider.

_______________________________________ ____________________________________

Name Relationship to Child

_______________________________________ ____________________________________


_______________________________________ ____________________________________


_______________________________________ ____________________________________

Parent/Guardian Signature Date

Communication Consent

In compliance with federal law, it is the Policy of Peds Care, P.C. to NOT leave confidential information on answering

machines, voice mail, e-mail, or with unauthorized individuals who are not listed on the consent to treat form. If you

would prefer that we leave this information on a designated voicemail in the instance that we are unable to reach you,

please specify the phone number where we can leave a detailed voicemail.

______________________________ _________________________ ________________________________

Name Phone Number Relationship to Child

______________________________ _________________________ ________________________________


______________________________ _________________________ ________________________________


_______________________________________ ____________________________________

Parent/Guardian Signature Date

Consentimiento para tartar FORM #: PEDS 113

Tenga en cuenta que solo un padre o tutor legal debe completar este formulario. Si no es el padre / tutor legal, deje este formulario

en blanco. Gracias.

Nombre: _______________________________ Fecha de Nacimiento:______________

Indique las personas a continuación que cuenten con su consentimiento para autorizar el tratamiento médico, aprobar vacunas, retirar

recetas, hablar con el personal por teléfono con respecto a su hijo o cualquier otra cosa que el proveedor de atención médica considere

necesaria.

_____________________________________ ____________________________________

Nombre Relación con el niño


____________________________________


_______________________________________ ____________________________________

Firma del padre/tutor Fecha

Consentimiento de comunicación

De conformidad con la ley federal, es la Política de Peds Care, P.C. NO dejar información confidencial en contestadores automáticos,

correo de voz, correo electrónico o personas no autorizadas que no figuran en el formulario de consentimiento para tratar. Si prefiere

que dejemos esta información en un correo de voz designado en el caso de que no podamos comunicarnos con usted, especifique el

número de teléfono donde podemos dejar un mensaje de voz detallado.

______________________________ _________________________ ________________________________

Nombre Número de teléfono Relación con el niño

______________________________ _________________________ ________________________________


______________________________ _________________________ ________________________________


_______________________________________ ____________________________________

Firma del padre/tutor Fecha

FORM #: PEDS 114 ACCT #

HIPAA Privacy Rule

Receipt of Notice of Privacy Practices

Written Acknowledgement Form

Acknowledgement of receipt of Information Practices Notice (§164.520(a))

I (Childs Name) _______________________________, understand that as part of my healthcare, this

facility originates and maintains health records describing my health history, symptoms, examination

and test results, diagnosis, treatment and any plans for future care or treatment. I acknowledge that I

have been provided with and understand that this facility’s Notice of Privacy Practices provides a

complete description of the uses and disclosures of my health information. I understand that:

• I have the right to review this facility ‘s Notice of Privacy Practices prior to signing this

acknowledgement

• This facility reserves the right to change their Notice of Privacy Practices and prior to

implementation of this will mail a copy of any revised notice to the address I've provided if

requested.

Signature of Individual or Legal Representative Witness ___________________________________

Printed Name of Individual or Legal Representative ______________________________________

Date: ________________

FOR OFFICE USE ONLY

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but it

could not be obtained because:

Individual refused to sign

Communication barrier prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Others (please specify)

__________________________________________________________________


Regla de Privacidad HIPAA

Recibo de Noticia de Practicas Privadas

Forma de Reconocimiento Escrita

Reconocimiento de recibo de Noticias de Practicas de Información (§164.520(a))

Yo, ______________________________________; entiendo que, como parte de mi cuidado de salud,

esta instalación origina y mantiene registros de salud describiendo mi historial de salud, síntomas,

resultados de pruebas y exámenes, diagnósticos, tratamientos y cualquier tratamiento o cuidado de

salud futuro. Reconozco que se me ha provisto con, y he entendido, que la Noticia de Practicas Privadas

de estas instalaciones proveen una descripción completa de los usos y divulgaciones de mi información

de salud. Entiendo que:

• Tengo el derecho de revisar las Noticias de Practicas Privadas de estas instalaciones antes de

revisar el reconocimiento

• Estas instalaciones se reservan el derecho de cambiar sus Noticias de Practicas Privadas y antes

de la implementación de las mismas enviaran una copia por correo electrónico de cualquier

revisión a la dirección que he provisto, si se me pide.

Firma del Individuo ________________________________________

Nombre Impreso del Individuo ________________________________________

Fecha: _______________

SOLO PARA USO DE OFICINA – FOR OFFICE USE ONLY

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but it

could not be obtained because:

Individual refused to sign

Communication barrier prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Others (please specify)

______________________________________________________________________

______________________________________________________________________


Consent and Authorization for Minors FORM #: PEDS 115

If a minor is brought in to Peds Care, P.C. by someone other than the birth parent/custodial parent or

legal guardian, the minor child must be accompanied by a note (“Authorization”). Authorization must

include the date when it was written, name of the patient, name of the person bringing the child, what

the child is being seen for, the birth/custodial parent or legal guardian’s signature and a telephone

number where the birth/custodial parent or legal guardian can be reached.

I, ______________________________, (Circle your relationship to the patient: parent/legal guardian/grandparent)

PRINT YOUR NAME

Give consent for the individual identified below to bring the minor child to the Peds Care, P.C. office for

medical treatment. I hereby authorize the Peds Care, P.C. Pediatric physicians and other personnel, to

render medical care to my minor child in accordance with the Authorization without obtaining

additional consent from me.

___________________________________________ _________/_________/_________

PRINT FULL NAME OF MINOR CHILD (patient) DATE OF BIRTH (patient)

___________________________________________ ____________________________

Print Name of person bringing minor in for the appointment Relationship to Minor

(_____ )__________________________________

Phone number where parent/legal guardian can be reached

_______________________________________ ___________________

Signature of Parent or Legal Guardian Date

Consentimiento y Autorización para Menores FORM #: PEDS 115

Si un menor es traído a Peds Care, P.C. por otra persona que no sea el padre biológico / padre con

custodia o tutor legal, el menor deberá ir acompañado de una nota ("Autorización"). La autorización

debe incluir la fecha en que fue escrita, el nombre del paciente, el nombre de la persona que trae al

niño, para qué se ve al niño, la firma del padre / custodio o tutor legal, y un número de teléfono donde

se puede contactar al padre / madre o tutor legal de nacimiento / custodiaI

Yo, ______________________________,(Circular su relación con el paciente: padre / tutor legal/abuelo)

IMPRIMA SU NOMBRE

Doy consentimiento para que la persona identificada a continuación lleve al menor a Peds Care, P.C.

oficina para tratamiento medico Por la presente autorizo a Peds Care, P.C. Médicos pediátricos y otro

personal, para prestar atención médica a mi hijo menor de acuerdo con la Autorización sin obtener un

consentimiento adicional de mi parte.

___________________________________________ _________/_________/_________

IMPRIMIR NOMBRE COMPLETO DE HIJO MENOR FECHA DE NACIMIENTO (paciente)

___________________________________________ ____________________________

Imprimir Nombre de la persona que trajo a un menor para la cita Relacion con el Menor

(_____ )__________________________________

Número de teléfono donde se puede contactar al padre / tutor legal

_______________________________________ ___________________

Firma del padre o tutor legal Fecha

CONSENT FOR PATIENTS 18 YRS & OLDER- FORM #: PEDS 116

Name: __________________________________ Birthdate ____________

Because you are 18 years of age or older, anyone that you wish to have access to your medical

information must be listed on this document. Whether in person or over the phone, this

individual can schedule office appointments, speak to nurses, pick up prescriptions or other

forms, and/or receive personal information concerning you.

_____________________________________ ______________________________________

Name Relationship to Patient

_____________________________________ ______________________________________


_____________________________________ ______________________________________


Do you want information regarding sexual health disclosed to these individuals? This includes

screening or treatment for STD’s and/or pregnancy. □ Yes □ No

□ I DO NOT authorize anyone other than myself to access my protected health information for

ANY reason.

If a member of Peds Care, P.C. is unable to reach you at the phone number you have provided,

please select any information that can be left on your voicemail

□ Appointment Reminders □ Lab Results □ Referral Information □ Financial Information

By signing the following, I understand that a written request must be submitted in order to

make changes to, or revoke this authorizaiton.

____________________________________ _______________________________________

Patient Signature Date

____________________________________ _______________________________________

Witness Signature Date

CONSENTIMIENTO PARA PACIENTES MAYORES DE 18 AÑOS FORM #: PEDS 116

Nombre: __________________________________ Fecha de Nacimiento: ____________

Debido a que tiene 18 años de edad o más, cualquier persona que desee tener acceso a su información

médica debe de estar en este documento. Ya sea en persona o por teléfono, esta persona puede

programar citas en la oficina, hablar con enfermeras, recoger recetas u otros formularios y / o recibir

información personal sobre usted.

____________________________________ ______________________________________

Nombre Relacion al Paciente

_____________________________________ ______________________________________


_____________________________________ ______________________________________


Desea que se de información sobre su salud sexual a estas personas? Esto incluye exámenes de

detección o tratamiento para enfermedades de transmisión sexual y / o embarazo. □ Si □ No

□ YO NO autorizo a nadie más que a mí a acceder a mi información de salud protegida por CUALQUIER

motivo.

Si es miembro de Peds Care, P.C. no puede comunicarse con usted al número de teléfono que ha

proporcionado, seleccione cualquier información que pueda dejarse en su correo de voz

□ Recordatorios de citas □ Resultados de laboratorio □ Información de referencias

□ Información financieras

Al firmar lo siguiente, entiendo que debe enviarse una solicitud por escrito para realizar cambios o

revocar esta autorización.

____________________________________ _______________________________________

Firma del Paciente Fecha

____________________________________ _______________________________________ Firma de testigo

Fecha

State of Georgia Immunization Office

VACCINES FOR CHILDREN (VFC) PROGRAM

Patient Eligibility Screening Record

Date: _________________ Provider/Physician: _________________________ MM/DD/YYYY

The Patient Eligibility Screening Record provides documentation to show VFC vaccines are being administered to VFC eligible children. Definitions VFC Eligible: Child meets eligibility criteria outlined in #4 below. Non-VFC Eligible: Any patient who does not meet VFC criteria or special populations defined by the Georgia

Department of Public Health (DPH) Immunization Program. A child who has health insurance that covers vaccines is considered fully insurance and is not eligible for VFC vaccines. This category also includes high-deductible plans which are also considered fully insured and ineligible for VFC and state supplied vaccine.

Instructions for use: 1) The Patient Eligibility Screening Record must be completed on the initial visit for each patient receiving vaccines

provided by the VFC Program. Subsequent screenings should be documented under the “Screening Updates” portion of the form. The parent/guardian should be asked at each visit if the child’s VFC eligibility status has changed. This form should be kept in the patient’s file for a minimum of 3 years.

2) The Patient Eligibility Screening Record should be maintained in the patient’s file or a central file in your office.

If your billing system captures VFC eligibility, you can document eligibility electronically instead of using the paper form. However, eligibility for any given date of service in history must be researchable and verifiable for that date.

The method of documentation is flexible as long as your office can produce a list of VFC eligible patients if needed.

3) For Medicaid and PeachCare for Kids participants, a copy of the Medicaid or PeachCare for Kids card in the patient’s

medical record serves as appropriate eligibility documentation in place of the Patient Eligibility Screening Record. Things to know regarding PeachCare enrolled patients:

PeachCare enrolled patients are not VFC eligible however, an agreement is in place between the

Department of Public Health and PeachCare which allows doses to be administered to PeachCare enrolled patients from your state supplied vaccine inventory.

Office staff must be able to differentiate between a PeachCare enrolled patient with Medicaid as the payee

vs. a PeachCare enrolled patient with PeachCare as the payee. When Medicaid is the payee, the patient should be indicated as Medicaid covered.

4) Children eligible for Georgia VFC include children birth through 18 years of age who are:

Medicaid Enrolled Uninsured (child has no health insurance coverage) Underinsured (child has insurance that does not cover vaccines, seen in a Federally Qualified Health Center

or Rural Health Center)* American Indian or Alaska Native

*The Georgia Department of Public health has made funding available for state supplied vaccines to be administered to underinsured patients seen in a non-FQHC or RHC. So while these patients are not VFC-eligible, they are eligible for state supplied doses.

Patient Eligibility Screening Record

Vaccines for Children Program

This provider participates in the Vaccines for Children Program (VFC). If you meet the requirements of this program, we can provide your child’s immunizations at a reduced fee. In order to determine eligibility, we must know if your child has insurance that pays for immunizations.

Child: Date of Birth:

Last Name First Name MI MM/DD/YYYY

Parent/Guardian: Last Name First Name MI

INELIGIBLE FOR STATE-SUPPLIED VACCINE (Check if applicable)

The child 18 years of age or younger has insurance that pays for immunizations. (Fully-insured / Private Pay, includes high deductible plans)

ELIGIBLE FOR STATE-SUPPLIED VACCINE This child 18 years of age or younger qualifies for vaccination with state-supplied vaccine because (check only one box):

The child is enrolled in Medicaid

The child is American Indian or Alaska Native

The child does not have health insurance (Not Insured)

The child has health insurance that does not pay for vaccines (Underinsured)

The child is enrolled in PeachCare for Kids

Note to Providers: A record must be kept in the healthcare provider’s office that reflects the status of all children 18 years of age or younger, who receive immunizations with vaccines supplied by state programs. While verification of responses is not required, it is necessary to retain this or a similar record for each child receiving vaccine.

S C R E E N I N G U P D A T E S

DATE SCREENED

State Supplied Vaccine Eligible

(Check only one category) NOT

ELIGIBLE

PEACHCARE FOR KIDS

MEDICAID ENROLLED

UNINSURED

AMERICAN INDIAN OR

ALASKA NATIVE

UNDER-INSURED

INSURANCE COVERS

VACCINATIONS

Documents

New Patient History FORM #: PEDS 110...correo de voz, correo electrónico o personas no autorizadas que no figuran en el formulario de consentimiento para tratar. Si prefiere que dejemos