Policies & Forms
Patient Information
Rainbow Kids Pediatrics
PATIENT PERSONAL INFORMATION
Name:_____________________________________________ DOB:_____________ ⟡ Female ⟡ Male
Street:_____________________________________________________ Apartment #:_________________
City: _________________________________________ State:____________ Zip Code:________________
Home Phone:________________Parent’s Cell 1:________________Parent’s Cell 2:________________
How did you hear about us?_______________________________________________________________
PARENT/RESPONSIBLE PARTY INFORMATION
Name:_________________________________________ DOB:_____________ SS#:__________________
Relationship to Patient:_____________Home Phone:______________Work Phone:_______________
Street:_____________________________________________________ Apartment #:_________________
City: _______________________________________ State:____________ Zip Code:__________________
Employer:____________________________________ Occupation:________________________________
Secondary Insurance Company Name:______________________________________________________
Policy Number:_______________________________ Group Number:_____________________________
SECOND PARENT/SECONDARY INSURANCE INFORMATION -Secondary Insurance? ⟡ Yes ⟡ No
Name:_________________________________________ DOB:_____________ SS#:__________________
Relationship to Patient:_____________ Home Phone:______________ Work Phone:______________
Street:_____________________________________________________ Apartment #:_________________
City: _______________________________________ State:____________ Zip Code:__________________
Employer:____________________________________ Occupation:________________________________
Secondary Insurance Company Name:______________________________________________________
Policy Number:_______________________________ Group Number:_____________________________
EMERGENCY CONTACT INFORMATION
Name of person not living with you:________________________________________________________
Address:__________________________________________ City/State:_____________________________
Home Phone:___________________ Work Phone:___________________ Zip Code:_________________
I hereby give lifetime authorization for payment of insurance benefits to be made directly to Rainbow Kids Pediatrics, and any assisting physicians, for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all cost of collections, and reasonable attorney’s fees. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original.
I hereby give lifetime authorization and voluntary consent to Rainbow Kids Pediatrics and it's staff to provide basic medical care for diagnosis and treatment which is understood as reasonable by the doctors for current presentation of signs and symptoms.
ACKNOWLEDGEMENT OF RECEIPT
I acknowledge that I received a copy of Notice of Privacy Practice.
Date:_____________________ Signature:_______________________________________________________
Financial Policy
Rainbow Kids Pediatrics Financial Policy
Payment is required at the time services are rendered unless other arrangements have been made in advance. This includes applicable coinsurance and co-payments for participating insurance companies. Rainbow Kids Pediatrics accepts cash, personal check, and most major credit cards. There is a service fee for returned checks of $35.
Patients with an outstanding balance of 60 days overdue must make arrangements of payment prior to scheduling appointments.
Insurance:
We bill participating insurance companies as a courtesy to you. You are expected to pay your deductible and co-payments at the time of service. If we have not received a payment from your insurance company within 45 days of the date of service, you will be expected to pay the balance in full. You are responsible for all charges. We do bill secondary insurance companies as a courtesy to you.
Managed Care:
If you are enrolled in a managed care insurance plan (i.e. HMO), you must receive a referral from our office before seeing a specialist. NO retroactive referrals will be given.
Missed Appointments and Late Cancellations:
Broken appointments represent a cost to us, to you and to the other patients who could have been seen in the time set aside for you. Cancellations are requested 24 hours prior to the appointment. We reserve the right to charge for missed or last minute cancellations. Excessive abuse of scheduled appointments may result in discharge from the practice.
I have read and understand the Rainbow Kids Pediatrics Financial Policy. I agree to assign insurance benefits to Rainbow Kids Pediatrics whenever necessary. I also agree that if it becomes necessary to forward my account to a collection agency, in addition to the amount owed, I will also be responsible for the fee charged by the collection agency for cost of collections.
Signature of insured or authorized representative:
_________________________________________________________ Date:__________________________
Patient Name:_____________________________________________ Patient DOB:___________________
Privacy Policy
Notice of Privacy Practices
Carol Herrmann, M.D.
755 Commerce Drive #503
Decatur, Georgia 30030
Phone: 404-378-1998
Fax: 404-941-2642
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This notice describes how we protect your health information and your rights regarding privacy.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS: The most common reason why we disclose your health information is for treatment, payment or health care operation. “Health care operations” mean those administrative functions that we have to do to run our office. Examples are: financial or billing audits, participants in managed care plans, and defense of legal manners. We routinely use your health information for these purposes without written permission. We will ask for written permission to release information to any other entity that does not pertain to our office’s treatment, payment, or health care operations.
USES AND DISCLOSURES OF ANY OTHER REASONS WITHOUT PERMISSION: The law allows or requires us to release your health information without your permission in certain situations. Such uses or disclosures are: when a law mandates that certain health information be reported for a specific purpose, for public health purposes such as infectious disease investigation, notices to the FDA regarding drugs or vaccines, disclosures to authorities regarding suspected abuse or neglect, for Medicaid or Medicare audits, disclosures for law enforcement purposes, for health related research, to prevent a serious threat to health or safety, and disclosures to business associates who perform health care operations for us and who commit to respect the privacy of your health information.
APPOINTMENT REMINDERS: We may call to remind you of scheduled appointments, or that it is time to make a routine appointment. Unless you tell us otherwise, we will leave you a reminder on your answering machine or with someone who answers your phone if you are not at home.
OTHER USES AND DISCLOSURES: We will not make any other uses or disclosures of your health information unless you sign a written authorization form. You may initiate the process if it’s your idea for us to send your information to someone else. If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign it, we cannot make the disclosure. If you do sign one, you may revoke it at any time, in writing. An example of this is a vaccination release for daycare.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION: The law gives you rights regarding your health information. You can ask us to communicate with you in a confidential way such as phoning you at work rather than at home or by mailing health information to another address. We will accommodate these requests if they are reasonable and you pay us for any additional costs. If you want to ask for confidential communications, send a written request to the office. You may review or have a copy of your health information within 30 days of asking us in writing. You may have to pay for photocopies in advance. You may ask us to amend your health information if you think it is incorrect or incomplete. We will send corrected information to persons we know got the wrong information and others that you specify. If you do not agree, you can write a statement of your position, and we will include it in your health information along with any rebuttal statement that we may write. These will be included in any permitted disclosures of your health information. If you want to ask us to amend your medical record, send a written request to the office. You are entitled to one list of disclosures of your health information per year, without charge. By law, the list will not include: disclosures of treatment, payment or health care operations; disclosures with your authorizations; disclosures required by law; and some other limited disclosures. If you want a list, send a written request to the office. You may get another copy of this privacy policy by sending a written request to the office.
OUR NOTICE OF PRIVACY PRACTICES: By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change our policy, we will post the new notice in our office and have copies available in our office.
COMPLAINTS: If you think we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Dept. of Health and Human Services, Office of Civil Rights. We will not retaliate against you if you make a complaint. If you want to make a complaint to us, you may do so in person, over the phone, or you may put it in writing.
For more information about our privacy practices, call or visit the office.