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ABC PEDIATRICS, LTD
☐Gus Rousonelos, MD ☐Erin Shanks, MD ☐Karolyn Law, MD ☐Ushma Patel, MD ☐Pamela Persak, MD PATIENT INFORMATION
First Child Second Child Third Child Fourth Child
First Name Middle Name Last Name Date of Birth Sex ☐Male ☐Female ☐Other ____________ ☐Male ☐Female ☐Other ____________ ☐Male ☐Female ☐Other ___________ ☐Male ☐Female ☐Other ___________ Primary Language
Ethnicity ☐Not Hispanic ☐Hispanic ☐Unknown ☐Decline ☐Not Hispanic ☐Hispanic ☐Unknown ☐Decline ☐Not Hispanic ☐Hispanic ☐Unknown ☐Decline ☐Not Hispanic ☐Hispanic ☐Unknown ☐Decline
Race ☐Native American
☐Black ☐Asian ☐White ☐Pacific Islander ☐ Decline ☐Native American ☐Black ☐Asian ☐White ☐Pacific Islander ☐ Decline ☐Native American ☐Black ☐Asian ☐White ☐Pacific Islander ☐ Decline ☐Native American ☐Black ☐Asian ☐White ☐Pacific Islander ☐ Decline PATIENT ADDRESS Address: City, State, Zip:
Mail Statements to this address? ☐Yes ☐No
PRIMARY PHONE: IS THIS A CELL PHONE? ☐Yes ☐No
How would you prefer to be contacted for appointment reminders? ☐ Text to cell ☐ Email
CONTACT INFORMATION
FIRST CONTACT (PARENT/GUARDIAN) SECOND CONTACT (PARENT/GUARDIAN)
Last Name: Last Name:
First Name: First Name:
Relationship: DOB: Relationship: DOB:
Address: Address:
City, State, Zip: City, State, Zip:
Mail Statements to this contact? ☐Yes ☐No Mail Statements to this contact? ☐Yes ☐No
Cell Phone: Cell Phone:
Work Phone: Work Phone:
Email Address: Email Address:
Are you the primary insurance carrier? ☐Yes ☐No Are you the primary insurance carrier? ☐Yes ☐No Are you the primary contact? ☐Yes ☐No Are you the primary contact? ☐Yes ☐No
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AUTHORIZATION FOR THE TREATMENT OF MINORS
I authorize the following to bring my child/ren listed above to A.B.C. Pediatrics, Ltd. for medical care without my express prior authorization.
Name:
Phone number: Relationship to patient:
Name:
Phone number: Relationship to patient:
Name:
Phone number: Relationship to patient:
Name:
Phone number: Relationship to patient:
PREFERRED PHARMACY
Name: Phone:
Address: City, State, Zip:
AUTHORIZATION AND ACKNOWLEDGEMENT
I understand copies of the Notice of Privacy Practices (HIPAA), Financial Policy, Cancellation/No Show Policy, and Electronic Communication Policy are posted in the office and on our website, www.abcpediatrics.net. I understand that I am bound by the terms of these policies and failure to do so could result in dismissal.
I authorize you to give my child/children reasonable and proper medical care by today’s standards. I authorize the physician to release information related to any claim.
I recognize and accept full responsibility for all professional services rendered and further authorize the insurance
company to pay benefits directly to the physician.
I understand that I am personally responsible for being aware of the dates and times of my scheduled appointments. I understand that I must give at least one-hour notice when canceling a sick appointment and at least 24-hour notice
when canceling a well visit, otherwise I will be charged a $50 fee.
I understand that I am responsible for deductibles or uncovered expenses. This may include charges for screening
forms, lab tests, and vision screenings that are required by law or recommended by the American Academy of Pediatrics.
I understand that an additional charge will be incurred for patients seen in the office during regularly scheduled
evening, weekend or holiday office hours.
Signature: ___________________________________________________________
Print Name: _______________________________________________
ABC Pediatrics, Ltd.
Infant Pediatric Health History Form—Initial Visit
Child’s Name _____________________Age _____
Your Name ________________________________
Pregnancy and BirthMaternal Exposures:
Medication? No Yes _______________ Drugs/Alcohol? No Yes _______________ Tobacco? No Yes _______________ Infection/Grp B strep? No Yes _______________
Birth problems for patient:
Jaundice? No Yes _______________ Infection? No Yes _______________ Breathing? No Yes _______________ Low Blood Sugar? No Yes _______________ Oxygen Use? No Yes _______________ NICU stay? No Yes _______________ Was your child premature? No Yes, born at ____weeks Delivery: vaginal c-section breech forceps Where was your child born? _________________________ Is the child yours by birth adoption stepchild other Birth weight ________________ Length ______________ Mother’s blood type? ________________________________ Other problems in the newborn period __________________ _________________________________________________ Past Medical History of Your Infant
Any medications taken regularly? No Yes Which ones? ______________________________________ Any allergic reactions to medications? No Yes Which ones? _______________________________________ Any reactions to immunizations? No Yes Which ones? _______________________________________ Any hospitalizations other than for birth? No Yes For what? _________________________________________
Other history? No Yes
Which kind? _______________________________________ Safety / Environment
Is your water heater set to 120 degrees? Yes No Is there a working smoke alarm on each
floor in the house? Yes No
Does your child always use a car seat
in the back seat when riding in the car? Yes No Do you place your baby to sleep on
his/her stomach? No Yes
Do you have help or support easily
available? Yes No
Any stresses in the family? No Yes Describe _________________________________________ _________________________________________________ _________________________________________________ Where does the baby sleep: _____parents’ room, ____nursery ______sibling’s room, ______other?
Child’s DOB ____________ Today’s date _______
Relationship to Child ________________________
Feeding and NutritionAny unusual feeding problems? No Yes
Breast or formula fed? _______________________________ If on formula, which one? ____________________________ Does he/she take vitamins? ___________________________ If breastfeeding, how long do you plan to continue? ________ Review of systems
Any eye problems? No Yes
Difficult or noisy breathing? No Yes Heart murmur or heart problem? No Yes Problem with stools (diarrhea/constipation)? No Yes Is he/she irritable or colicky? No Yes
Any skin conditions? No Yes
Problem with vomiting or excessive spit up? No Yes Please list any other medical problems or explain above problems. _________________________________________ _________________________________________________ Social History
Who lives in the child’s household? Mom Dad Step ___ Siblings (# ___) Grandparents Other ________ Child’s parents are married unmarried divorced other Mom’s Occupation __________Dad’s Occupation_________ Childcare parents relatives daycare babysitter/nanny Days per week in childcare (not with parent) ______
Any pets? Yes No ______________________________ Do any household members smoke? Yes No
Is there a gun in the home? Yes No
Is it locked and separate from ammunition? Yes No
Family History
Do any family members have any of the following conditions:
Please explain all positives.___________________________ __________________________________________________
ABC Pediatrics, Ltd.
Pediatric Health History Form—Initial Visit
Child’s Name ______________________________
Your Name ________________________________
Child’s Past Medical History
Pregnancy/Neonatal Period
Where was your child born? _________________________ Is the child yours by birth adoption stepchild other Delivery: vaginal C-section
Was your child premature? No Yes, born at ____weeks Birth weight ________________ Length ______________ Other problems in the newborn period __________________ _________________________________________________ Infancy/Childhood/Adolescence
Has your child ever been treated or diagnosed with: (explain) Asthma or reactive airway disease ____________ Wheezing or bronchiolitis __________________ Seasonal allergies _________________________ Eczema _________________________________ Food allergy _____________________________ Recurrent ear infections ____________________ Pneumonia _______________________________ Urinary tract infections ______________________ Seizures __________________________________ Anemia __________________________________ Broken bone /concussion ____________________ Depression/anxiety _________________________ Heart murmur _____________________________ Constipation ______________________________ Chicken pox ______________________________ Attention Deficit Disorder ___________________ Other chronic medical conditions ______________________ _________________________________________________ Has your child ever been hospitalized? No Yes (explain) _________________________________________________ Previous surgeries and dates __________________________ _________________________________________________ Please list any specialist your child has seen, dates and reason: _________________________________________________ _________________________________________________ Medications
ALLERGIES to medicine/vaccines (list and describe reaction) _________________________________________________ _________________________________________________ Current medications and dose: ________________________ _________________________________________________ _________________________________________________ Development/Nutrition
Did/does your child have delayed development? No Yes How does this child compare to others his or her age? _____ _________________________________________________ What grade is he/she in? ____________________________ Has she/he had any trouble in school? No Yes Does he/she get along with other children? No Yes Do any foods disagree with him/her ? No Yes Which ones? _____________________________________ Does he/she get fluoride? No Yes How many hours per day does your child spend:
Watching TV _____ Computer _____ Video games _____ Hobbies/extracurricular activities __________________
Date of Birth ___________________ Age ______
Relationship to Child ______ Today’s date_______
Social History
Who lives in the child’s household? Mom Dad Step ___ Siblings (# ___) Grandparents Other ________ Child’s parents are married unmarried divorced other Mom’s Occupation __________Dad’s Occupation_________ Childcare parents relatives daycare babysitter/nanny Days per week in childcare (not with parent) ______
Any pets? Yes No ______________________________ Do any household members smoke? Yes No
Is there a gun in the home? Yes No
Is it locked and separate from ammunition? Yes No
Family History
Do any family members have any of the following conditions:
Please explain all positives: ___________________________ _________________________________________________ _________________________________________________ _________________________________________________
Review of systems
Please review the topics listed below. Check if you have a concern about your child:
Physical problem Development Sleep patterns Snoring
Diet/nutrition/weight Amount of physical activity Emotional development Relationships with parents Self-image or self-worth Depression
Anxiety/stress
Attention/impulsivity Acting out/behavior issues School grades/absences
ABC PEDIATRICS, LTD
1331 W. 75
thStreet
Suite 300
Naperville, IL 60540
Phone (630) 355-0003
Fax (630) 355-9822
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY POLICIES
I understand that under the Health Insurance Portability and Accountability Act (HIPAA) of
1996, I have certain rights to privacy regarding my protected health information. I hereby give
my consent to ABC Pediatrics, LTD to use or disclose, for the purpose of carrying out treatment,
payment, or health care operations all information contained in the patient record(s) of:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
I understand that this information will be used to:
conduct, plan, and direct my treatment and follow-up among the multiple healthcare
providers who may be involved in that treatment directly or indirectly
obtain payment from third party payers
conduct normal healthcare operations such as quality assessments and physician
certification
I understand that I may revoke this authorization at any time by giving written notice to ABC
Pediatrics, LTD of my desire to do so. I also understand that I will not be able to revoke this
authorization in cases where the physician has already relied on it to use or disclose my health
information. Written revocation must be sent to the physician office.
I understand that I can find the full copy of the privacy policy, as well as any changes made,
online at abcpediatrics.net/patients-forms.
____________________________________________________ _______________________ Signature of parent / guardian or assigned representative Relationship to child
__________________________________________________ _______________________
Gus Rousonelos, MD Erin Shanks, MD Karolyn Law, MD Ushma Patel, MD Pamela Persak, MD
1331 West 75th Street, Suite 300 Naperville IL 60540 P: (630) 355-0003 F: (630) 355-9822
Congratulations on your new family member!
This is an exciting time for your family, but it can also be overwhelming. The following
information is to help guide you through the process of adding your child to your insurance
policy.
Inform your employer’s human resource department or insurance agent as soon as
possible after your child’s birth or adoption. Most insurance providers require you to add
your child to your policy within 30 days from the child’s date of birth or adoption. If the
child is not added to the plan within this timeframe, your insurance policy may require
you to wait until the next open enrollment period.
Fill out any necessary paperwork from your employer or insurance company (check your
insurance provider’s website; you may be able to do this online).
Request your child’s birth certificate and social security number; your insurance
provider will need copies of these.
Call or check the website of your insurance plan to verify coverage and benefits. It’s
important that you’re aware of your benefits and any limitations on your policy. We can
supply you with a form to ask specific questions.
Keep us informed when the child has been added to insurance or of any delay in
coverage. Communication is very important to ensure claims are sent to your insurance
provider in a timely manner. If we are unable to confirm your child’s participation in
your plan after 30 days, you may be responsible for any charges incurred.
We sincerely appreciate you choosing ABC Pediatrics, Ltd. as your child’s medical home. Please
let us know if you have any questions regarding insurance, we are here to help!
Gus Rousonelos, MD Erin Shanks, MD Karolyn Law, MD Ushma Patel, MD Pamela Persak, MD
1331 West 75th Street, Suite 300 Naperville IL 60540 P: (630) 355-0003 F: (630) 355-9822
Questions for Your Insurance Plan
Please contact your insurance carrier using the toll free number on the back of your insurance card and ask if we are in their network. If needed, please provide our tax ID number: 36-4122365.
The following are questions to ask to verify benefits:
Name of insurance company: _________________________ Type of plan: PPO, POS, EPO or other
Name of network: __________________________________ Effective date of policy: ______________________________ Deductible amount:
Individual $ __________ Family $ __________ Date deductible starts over ____________________________ What services are subject to deductible?
Hospital Office Visits Immunizations Labs Wart Treatments Strep Tests Lab preferred provider: _____________________________
Medical /sick visit copay $ __________ Well baby/child care copay $ __________ Are immunizations covered? Yes/No At what percentage? _______
Are there any limits on immunizations? Yes/No If yes, dollar amount limit is $ _______ per _______ Are there any limits on well care? Yes/No If yes, dollar amount limit is $ _______ per _______ Number of visits limit is _______ per _______ Age limit? _______
We hope this provides you with a basic understanding of our financial policy. Our staff is trained to help you with any insurance questions you may have. Only your employer or insurance provider can address how your plan is administered, however. If you have any questions regarding our payment structure, please feel free to contact our office.