Pine Lake Health, LLC & Waverly Health Care
PEDIATRIC HEALTH HISTORY
PATIENT INFORMATION
GUARANTOR INFORMATION (Person whom is financially responsible for the patient
INSURANCE INFORMATION
Authorization to Pay Benefits to Physician: I authorize the release of medical or other information necessary to process health insurance claims. I also
request payment of benefits to myself or to my Provider, Pine Lake Health, LLC, when he/she accepts assignment.
Authorization to Release Medical Information: I hereby authorize my Provider, Pine Lake Health, LLC, to release any information necessary for my course of treatment.
Pediatric Health History
Past History:
Pediatric Health History (cont.)
Immunization: (please give dates or provide a copy of previous immunization record)
If current please write up to date.
Family History: (List relatives with any of the following problems)
Health Habits: (Circle most appropriate)
Tobacco exposure:
Development:
Age Child..
Pediatric Health History (cont.)
Has this child had any of the following problems: (include both recent, past and present)
Mark with X current symptoms, √ for past symptoms
General
Digestive Tract
Skin
Head
Urinary
Lungs
Genitalia
Heart
Psychological
Behavior
CONSENT TO MEDICAL TREATMENT FOR MINOR CHILD
WITHOUT PARENT / LEGAL GUARDIAN PRESENT
By law in Nebraska, any child under the age of 19 years old cannot be seen by a doctor without consent from a parent
or legal guardian. If the minor arrives with someone other than a parent or legal guardian, we must have written
permission from the parent or legal guardian that this person has been appointed by you to act on your behalf.
For those occasions when you may not be with your child, please list those individuals who may give us consent to
see your child:
LIMITATIONS:
Identify any specific limitations on the kinds of medical services for which this authorization is given. (if none, state
‘none’ or ‘na’)
This consent shall be in effect for:
AUTHORIZATION:
I (parent/legal guardian name)
request and authorize
Pine Lake Health, LLC and its personnel to deliver routine medical care to my child listed above as may be
deemed necessary or advisable in the diagnosis and treatment of the minor child. I am also aware that
the adult presenting the child is responsible for payment of the patient portion at the time of service.
I have the legal right to preauthorize Pine Lake Health, LLC and its personnel to deliver routine medical
treatment and services to my child. Routine medical care and interventions may include, but are not
limited to: medical evaluation, physical exam, routine immunizations, injections, x-rays, lab work
(examples: throat or nasal swabs, blood draws, wart treatment, minor burns, minor suturing of lacerations)
and prescribing new medications.
I have the legal right to preauthorize Pine Lake Health, LLC and its personnel to deliver routine medical
treatment and services to my child. Routine medical care and interventions may include, but are not
limited to: medical evaluation, physical exam, routine immunizations, injections, x-rays, lab work
(examples: throat or nasal swabs, blood draws, wart treatment, minor burns, minor suturing of lacerations)
and prescribing new medications.
I have read, understand, and give my consent as stipulated above. My signature means that I have read
this form and/or have had it read to me and explained in the language that I can understand.
HIPAA DISCLOSURE
MESSAGE AUTHORIZATION
FINANCIAL POLICY AND PATIENT RESPONSIBILITIES
Thank you for choosing Pine Lake Health, LLC as your primary health care provider. We are committed to assisting you with timely insurance
filing and payment of your account. The following is a statement of our Financial Policy, which we require you to read and sign prior to initial visit.
Updated insurance information must be given to us at the time of service. We will require a copy of your insurance cards before services are
performed and these will be scanned into our system. We file all insurance claims in a timely manner. After filing, we allow 30 business days
for your insurance company to pay. If your insurance company fails to make payment, you will be responsible for payment in full.
Copays, Co-insurance and /or Deductibles – There may be some copay, co-insurance or deductible charges associated with certain medical
services and tests. Patient payment of the copay, co-insurance, or deductible is required at the time of service.
Pre-certification – Pre-certification or prior approval may be required by your health plan before certain procedures, tests, or surgeries are
performed. We will assist you in the pre-certification process by contacting your insurance company on your behalf. It is your responsibility to
confirm that you have been granted approval of certification before your appointment so you do not incur any unnecessary personal charges.
If the patient is a minor, the adult accompanying the child for treatment will ultimately be responsible for payment. We cannot become involved
in third party liabilities, personal injury, or custody issues to determine the responsible party for payment. We cannot accept an attorney’s letter
of payment guarantee If you have a past due personal balance on your account, you will need to contact the billing office to make payment
arrangements prior to receiving most services. Any account that is over 90 days past due will be sent to an independent collection service and
may be subject to reporting to the credit bureau and possible termination of the doctor/patient relationship
Other physician charges – Our practice is committed to providing the best treatment for our patients which may necessitate the outsourcing of
some services to other professionals. When this occurs, you may receive a statement from the provider of ancillary services such as Pathology,
Laboratory, and/or Radiology interpretation services, unless Pine Lake Health, LLC purchased these services
Other physician charges – Our practice is committed to providing the best treatment for our patients which may necessitate the outsourcing of
some services to other professionals. When this occurs, you may receive a statement from the provider of ancillary services such as Pathology,
Laboratory, and/or Radiology interpretation services, unless Pine Lake Health, LLC purchased these services
Motor Vehicle Accident – Medical insurance will be filed and any co pay, co-insurance or deductible is required to be paid at the time of service.
If no payment is received from the insurance company after 30 business days, it will become the patient’s responsibility. Filing claims to the
auto insurance is the responsibility of the patient.
Unless contractually prohibited by your insurance carrier, you may be personally charged the following additional fees. These fees will not
be filed to your insurance carrier and are the direct responsibility of the patient. Please initial to the left of each category to indicate your
acknowledgement.
I certify that the information given by me in applying for payment under my insurance contract is correct. I authorize any holder of medical or
other information about me to release to any third party payers (including Medicare and Medicaid) information needed for claims for health care
benefits. I request that payment of authorized health care benefits be paid and I assign the benefits payable for the physician services to the
physician or organization furnishing the services. I authorize such physician or organization to submit a claim to my health insurance carrier or any
other third party payer, including Medicare and Medicaid, on my behalf. I request payment of benefits under Title XVIII (Medicare and XIX
Medicaid) of the Social Security Act to Pine Lake Health, LLC. I understand that I am financially responsible for charges not covered by the
assignment, and I hereby guarantee timely payment in full of any such charges
By signing below, I acknowledge that I have read and fully understand this Policy and my financial
responsibilities as a patient of Pine Lake Health, LLC.
Authorization for the Release of Medical Information / Medical Records
Please send the following health information:
TO or FROM (circle one) :
TO:
Pine Lake Health / Waverly Health Care
2611 S. 70th St, Lincoln NE 68506 OR
13220 Callum Dr. Suite 4, Waverly NE 68462
(**do not send records to the Waverly address**)
Fax: 402-423-4201
(Please DO NOT fax more than 10 pages!
Records over 10 pages, please send via secure email or
place on CD & mail to our address)Please send the following health information:
Information to omit: State and Federal law protect the following information as directed by you, the patient.
If leaving practice, please provide us with the following (check all that apply):
The date of this authorization is
and shall remain in effect until
Conditions: We may not condition your right to receive health care services from us upon your signing of this authorization if you are
leaving our practice. However, if the treatment to be provided is for research purposes, your failure to sign this authorization will prevent
us from providing such treatment.
Further use and disclosures: When we use or disclose your health information to other parties as you have instructed in this authorization,
we will not have the ability to monitor whether your health information may be further used or disclosed by such parties. In such situation,
your disclosed health information may no longer be protected by federal and state laws.
Revocation: You have the right to revoke this authorization at any time by notifying the providing organization in writing.
When we receive your revocation, we will immediately stop using or disclosing the health information you authorized us to use and
disclose in this authorization form. Your revocation shall not apply to those uses and disclosures we made on your behalf pursuant to this
authorization prior to the time we received your written revocation.
Reimbursement: Pine Lake Health, LLC reserves the right to recover the cost involved in producing the requested health information.
You or the party to receive disclosures, named able, may be charges $20.00 plus 50 cents per page for handling and coping this
information.
I authorize the use and disclosure of the medical records and health care information indicated above:
