Registration Form

C & M KINTIROGLOU MD's PA
1500 Pleasant Valley Way, Suite 301 West Orange, NJ 07052 973-243-0002
PATIENT INFORMATION



PHARMACY INFORMATION:



 
EMPLOYER INFORMATION/BENEFIT PROVIDER INFORMATION:
 
 
HOUSEHOLD:
PLEASE LIST ALL THOSE LIVING IN THE CHILD'S HOME.
 
BIRTH HISTORY:
   VAGINAL    CESAREAN

IF CESAREAN, EARLY OR LATE, PLEASE EXPLAIN WHY?
GENERAL:
YES    NO, EXPLAIN:
YES    NO, EXPLAIN:
YES    NO,EXPLAIN:
YES    NO,EXPLAIN:
YES    NO,EXPLAIN:
FAMILY HISTORY:
HAVE ANY FAMILY MEMBERS HAD THE FOLLOWING? PLEASE CIRCLE (YES) OR (NO):
DEAFNESS   YES   No WHO:
NASAL ALLERGIES   YES   No WHO:
ASTHMA   YES   No WHO:
TUBERCULOSIS   YES   No WHO:
HEART DISEASE
(BEFORE 50 YEARS OLD)
  YES   No WHO:
HIGH BLOOD PRESSURE
(BEFORE 50 YEARS OLD)
  YES   No WHO:
HIGH CHOLESTEROL:   YES   No WHO:
ANEMIA   YES   No WHO:
BLEEDING DISORDER:   YES   No WHO:
LIVER DISEASE:   YES   No WHO:
DIABETES:   YES   No WHO:
BED-WETTING
(AFTER 10 YEARS OLD)
  YES   No WHO:
EPILEPSY   YES   No WHO:
CONVULSIONS   YES   No WHO:
ALCHOL ABUSE:   YES   No WHO:
DRUG ABUSE:   YES   No WHO:
MENTAL ILLNESS:   YES   No WHO:
MENTAL RETARDATION   YES   No WHO:
IMMUNE PROBLEMS:
(HIV OR AIDS)
  YES   No WHO:
 
PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE
I, the undersigned, give my authorization to treat and assign directly to Kintiroglou Pediatrics, all medical benefits if any, otherwise payable to me for services rendered. I understand that I am ultimately financially responsible for all approved and covered charges whether or not be paid by insurance. I authorize the doctor to release all information necessary to secure that payment benefits. I authorize that use of this signature on all my insurance submissions. I understand that payment is expected at the time of service. I also understand that there are administrative fees that I might incur related to non-direct medical care such as school forms, copying of charts, missed appointments, etc. I will be responsible for any bills that incur if insurance is terminated, rebilling fees related to this or any bill, as well as any collection, court costs and improper scheduling of check-ups.
I AUTHORIZE THE PRACTICE TO USE AND DISCLOSE MY HEALTH ONFORMATIN FOR PURPOSES OF TREATING PATIENT, OBTAINING PATEMENT FOR SERVICES RENDERED TO ME AND CONDUCTING HEALTHCARE OPERATIONS. I ACKNOWLEDGE THAT THERE IS A COPY OF THE HIPPA PRIVACY PRACTICES NOTICE POSTED IN THE OFFICE.
 
______________________________ ________________________
PARENT/GUARDIAN SIGNATURE DATE OF SIGNATURE

ADVANCE BENEFICIARY NOTICE (ABN)
 
TRANSCUTANEOUS BILIRUBINOMETRY
(BILICHECK)
$30.00
 
Your health insurance may not pay for the cost of CPT Code: 88720. The fact that insurance may not pay for a particular service does not mean that you should not receive it, especially if your physician recommends that you receive this service.
 
________________________________ _______________________
SPOT VISION TEST
(AUTOMATED EYE SCREENING)
$25.00
 
USUALLY RECOMMENDED AT THE 12, 24, AND 36 MONTH WELL VISITS FOR VISION TESTING.
 
Your health insurance may not pay for the cost of CPT Code: 99174. The fact that insurance may not pay for a particular service does not mean that you should not receive it, especially if your physician recommends that you receive this service.
 
________________________________ _______________________

PRACTICE HEALTH INFORMATION AUTHORIZATION
 
Persons/Organizations authorized to use of disclosed information: C&M Kintiroglou M.D, PA
 
I hereby authorize the use and disclosure of my individually identifiable health information. I understand that this authorization is voluntary. Any heath information disclosed pursuant to this authorization may be subject to re disclosure by the recipients and may no longer be protected by the Federal privacy regulations.
***Please be specific and leave a detailed description in writing to the Office Manager if there’s a revoke request of medical health authorization.
 
_____________________ ____________________
 

ROUTINE CHECK-UP AND IMMUNINIZATION SCHEDULE
SUGGESTED BY OUR PRACTICE AND THE AMERICAN ACADEMY of PEDIATRICS
(Unless otherwise noted by one of the doctors)
     
  2 WEEKS
1 MONTH
2 MONTHS : FIRST IMMUNIZATION SCHEDULE
  • PEDIARIX
    • DTaP, Hep B, Polio
  • HIB #1
  • PREVNAR 13 #1
  • ROTA VIRUS #1
4 MONTHS: SECOND IMMUNIZATION SCHEDULE
  • PEDIARIX
    • DTaP, Hep B, Polio
  • PREVNAR 13 #2
  • ROTA VIRUS #2
  • HIB #2
6 Months: THIRD IMMUNIZATION SCHEDULE
  • PEDIARIX
    • DTaP, Hep B, Polio
  • HIB #3
  • PREVNAR 13 #3
9 Months: FOURTH IMMUNIZATION SCHEDULE
  • PPD
1 Year : FIFTH IMMUNIZATION SCHEDULE
(MUST BE AFTER 1ST BIRTHDAY)
  • PREVNAR 13 #4
  • HIB #3

18 Months: SEVENTH IMMUNIZATION SCHEDULE
  • DTaP
  • HepA #1
15 Months: SIXTH IMMUNIZATION SCHEDULE
  • MMR #1
  • VARICELLA #1
21 Months: NO IMMUNIZATION SCHEDULED AT THIS VISIT
(PLEASE CHECK WITH INSURANCE TO SEE IF THIS IS A COVERED VISIT)
2 Years: EIGHTH IMMUNIZATION SCHEDULE
  • Hep A #2
2 ½ YEAR: : NO IMMUNIZATION SCHEDULED AT THIS VISIT
(PLEASE CHECK WITH INSURANCE TO SEE IF THIS IS A COVERED VISIT)
3 YEAR: NO IMMUNIZATION SCHEDULED AT THIS VISIT
4 Year: NINETH IMMUNIZATION SCHEDULE
(MUST BE AFTER 4TH BIRTHDAY)
  • KINRIX
    • DTaP & POLIO
  • MMR #2
  • VARICELLA # 2

*YEARLY THEREAFTER


11 Years: TENTH IMMUNIZATION SCHEDULE
(OR BEFORE GOING INTO 6TH GRADE)
  • BOOSTRIX (TDAP)
  • MENVEO (MENINGOCCAL)
  • GARDASIL

*YEARLY THEREAFTER UNTIL THE AGE OF 21

 
     
I, , THE PARENT OF HAVE READ AND UNDERSTAND THE PRECEDING SCHEDULE. IF I HAVE ANY QUESTION OR CONCERNS I WILL DISCUSS THEM WITH THE PHYSICAN.
I, , THE PARENT OF UNDERSTANDS THAT I HAVE A RIGHT TO SEPARATE VACCINES. I ALSO UNDERSTAND THAT IF THE CHOICE TO SEPARTE VACCINES IS MADE WITHOUT THE RECOMMENDATION OF THE PHYSICAN A CO-PAYMENT AND/OR DEDUCTIBLE WILL BE APPLIED TO VACCINATION VISITS.
 
______________________________ ________________________
PARENT/GUARDIAN SIGNATURE DATE OF SIGNATURE

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