New Patient Packet | Northeast Pediatrics & Adolescent Medicine

Northeast Pediatrics & Adolescent Medicine

New Patient Intake Form

Child’s Name(Required)

First Last

Birth Date(Required)

Sex assigned at birth(Required)

Primary Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address (if different)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Race(Required)

Black/African American

American Indian/Alaska Native

Asian

Native Hawaiian/Other Pacific Islander

White/Caucasian

Declined to specify

Other

Ethnicity(Required)

Hispanic/Latino

Not Hispanic/Latino

Declined to specify

Primary Language(Required)

Secondary

Preferred Pharmacy:

Pharmacy Name(Required)

Pharmacy Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Contact

Check if also Responsible for Insurance/Billing (Primary Contact)

Check if also Responsible for Insurance/Billing

Primary Contact Name(Required)

First Last

Primary Contact Relationship to child(Required)

Primary Contact DOB(Required)

Primary Contact Phone Number(Required)

Primary Contact Cell Phone Carrier (Straight Talk, AT&T etc.)(Required)

Primary Contact Email(Required)

Primary Contact Address (if different than child)(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Secondary or Emergency Contact

Check if also Responsible for Insurance/Billing (Secondary Contact)

Check if also Responsible for Insurance/Billing

Secondary Contact Name

First Last

Secondary Contact Relationship to child

Secondary Contact DOB

Secondary Contact Phone Number

Secondary Contact Address (if different than child)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insurance Information

(Please be prepared to present your insurance cared at every visit)

Insurance Company

Name of subscriber (person who carries the insurance)

ID#

Group#

Effective Date

Subscriber’s Date of Birth

Relationship to child

What are the child’s living arrangements?(Required)

Lives with both parents in one home

Joint parental custody

Single parental custody

Lives with adoptive parents

Lives with Foster Family

Lives with extended family member

Other

Does anyone in the home smoke?(Required)

Indoor

Outdoor

If there are pets in the home what type?

Do they sleep in the child’s bedroom?

Yes

Does the home have smoke detectors?(Required)

Yes

Carbon monoxide Detectors?(Required)

Yes

Are there weapons in the home?(Required)

Locked

Unlocked

Please list everyone that is living in the home with the child including parent/guardian names.

Birth History

City/State/Country of Birth(Required)

Hospital(Required)

Full term pregnancy (37 weeks or more)?(Required)

If early, how many weeks?

Did the mother have any illness or complications during pregnancy? Please explain.(Required)

Was the delivery(Required)

Vaginal

Caesarian

If Caesarian, why?(Required)

Did your baby have any problems before leaving the hospital or in the first few weeks?(Required)

Yes

If yes, please explain(Required)

Birth Weight(Required)

APGARS(Required)

Pass Hearing Screen at Birth?(Required)

Yes

Not performed

In the hospital, was your baby:(Required)

	Yes	No
On oxygen?
On a ventilator?

Was your baby under bilirubin lights (phototherapy?)(Required)

Yes

If so how many hours?(Required)

Did your baby receive the Hepatitis B vaccine at birth?(Required)

Yes

If so what was the date of vaccine(Required)

Additional Birth Information

*If your child has been seen by additional providers or specialists a separate release of information is required to be signed for each office.

Child’s Medical History

Developmental Delay (Current or resolved)

Any surgeries, procedures, or hospital stays?

Major bodily injuries or head injuries?

Any serious illness?

Medications taken regularly (Include frequency & dose)

Checkmark all that apply(Required)

If you checked cancer above please specify type(Required)

Medications Taken Regularly

Family History

Please indicate relationship to the child, age of onset, and any additional information.

Allergies

Asthma

Eczema

Seasonal/Environmental Allergies

Cardiac

Unexpected death before age 50

Heart attack or stroke before age 50

High blood pressure

High cholesterol

Pacemaker/defibrillator

Hormonal

Diabetes

Thyroid problems

Other endocrine/hormone disorders (Specify)

Organ System Problems

Kidney disease

Liver disease

Lung disease

Bone disease

Gynecologic/reproductive disorders (Specify)

Neurologic

Seizures/epilepsy

Other neurologic disorders (Specify)

Mental Health

Depression/Anxiety

Obsessive-Compulsive Disorder

Schizophrenia

Bipolar disorder

Suicide attempt

Alcoholism

Drug abuse/addiction

Academic

Learning disability

ADD/ADHD

Autoimmune/Rheumatic Disorders

Lupus

Rheumatoid Arthritis

Ankylosing spondylitis

Cancer

Leukemia/Lymphoma

Melanoma

Testicular or Breast

Other (Specify)

Blood Disorders

Anemia

Hemophilia

Blood clots

Genetic disorders

Marfan syndrome

Cleft lip/cleft palate

Down syndrome

Other (Specify)

Please use the space below for additional history or information.

Authorization for Release of Health Information Pursuant to HIPAA

[This form has been approved by the New York State Department of Health]

Patient Name(Required)

First Last

Patient Phone(Required)

Patient Email(Required)

Date of Birth(Required)

Patient Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8. 2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).

Name and address of health provider or entity to release this information:(Required)

Name and address of person(s) or category of person to whom this information will be sent:(Required)

a). Specific information to be released:

Medical Record(Required)

Medical Record from Specific Date

Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers

Other

From(Required)

To(Required)

Include(Required)

Alcohol/Drug Treatment

Mental Health Information

HIV-Related Information

Authorization to Discuss Health Information

I authorize...(Required)

...to discuss my health information with my attorney, or a governmental agency, listed here:(Required)

Reason for release of information:(Required)

At request of individual

Other

Date or event on which this authorization will expire:(Required)

If not the patient, name of person signing form:

Authority to sign on behalf of patient:

All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form.

Date(Required)

Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infection and information regarding a person's contacts.

Instructions for the Use of the HIPAA-compliant Authorization Form to Release Health Information Needed for Litigation

This form is the product of a collaborative process between the New York State Office of Court Administration, representatives of the medical provider community in New York, and the bench and bar, designed to produce a standard official form that complies with the privacy requirements of the federal Health Insurance Portability and Accountability Act ("HIPAA”) and its implementing regulations, to be used to authorize the release of health information needed for litigation in New York State courts. It can, however, be used more broadly than this and be used before litigation has been commenced, or whenever counsel would find it useful. The goal was to produce a standard HIPAA-compliant official form to obviate the current disputes which often take place as to whether health information requests made in the course of litigation meet the requirements of the HIPAA Privacy Rule. It should be noted, though, that the form is optional. This form may be filled out on line and downloaded to be signed by hand, or downloaded and filled out entirely on paper. When filing out Item 11, which requests the date or event when the authorization will expire, the person filling out the form may designate an event such as "at the conclusion of my court case” or provide a specific date amount of time, such as “3 years from this date". If a patient seeks to authorize the release of his or her entire medical record, but only from a certain date, the first two boxes in section 9(a) should both be checked, and the relevant date inserted on the first line containing the first box.

Northeast Pediatrics & Adolescent Medicine

New Patient Intake Form

Preferred Pharmacy:

Primary Contact

Secondary or Emergency Contact

Insurance Information

Birth History

Child’s Medical History

Child’s Medical History

Family History

Authorization for Release of Health Information Pursuant to HIPAA

[This form has been approved by the New York State Department of Health]

Authorization to Discuss Health Information

Instructions for the Use of the HIPAA-compliant Authorization Form to Release Health Information Needed for Litigation

Services

Company

Resources

Sophie Sparrow, LMSW

Tiffany Lanza, CPNP-PC