How To Get A Medical Checkup From A Doctor

♥

WELCOME

♥

Metropolitan Pediatrics

, L.L.C.

WELCOME!

It is our pleasure to welcome your family to Metropolitan Pediatrics! We are very excited that you have chosen us, and can’t wait to get-to-know you, your care preferences, and health goals… so we can care for your family like no one else!

HOME SWEET

MEDICAL HOME

During your visit, we want you to feel welcome, cared for, and respected… just like you do in your own home! That’s why we make it easy and comfortable for you to get the care you need, in the way that works best for your family. As your Medical Home, we will:

♥ Listen to you and answer your

questions.

♥ Connect you to care,

information, and services to keep you healthy.

♥ Encourage you to have an

active role in your own health.

♥ Help and support you in any

way we can!

In return, we ask that you get involved in your care, team up with us to meet your health goals, and let us know when you have questions or concerns.

Immunizations are an essential part of well child care. Metropolitan Pediatrics follows the national immunization guidelines set forth by the American Academy of Pediatrics, the Advisory Committee on Immunization Practices of the Centers for Disease Control, and the American Academy of Family Physicians.

APPOINTMENTS

On weekdays, we are available by phone between 7:30am and

5:30pm, and see patients starting at 8:30am.

We do our best to accommodate same-day appointments. Call early as openings tend to fill quickly. Well Care

Please schedule check-ups 1 to 2 months in advance, so you can reserve a time that works best with your schedule.

Cancellations

We ask that you kindly give us 24-hour notice when canceling or rescheduling appointments. Preparation

At the time of your visit, you will be asked to present the following:

 copay, if applicable

 enclosed forms, completed

 health insurance card(s)

 photo ID

 current medications, including

dosage and strength

 current immunization records

 previous medical records, or

arrange for your previous physician to send records

24/7 ADVICE & SUPPORT

During business hours, we are happy to answer general questions over the phone. Urgent matters will be addressed before the day is over. For less urgent matters, we will return your call within 24-48 hours.

For after-hours advice, we offer a live answering service that can assist you, or connect you with on-call advice for guidance.

Reach Advice anytime, day or night, by calling your clinic’s daytime phone number.

WEEKEND CARE

Weekend appointments are available for patients with urgent

problems or certain pre-scheduled well exams. Our clinics are typically open through the morning and into the early afternoon, depending on patient demand.

If you feel your child has a medical problem that cannot wait until Monday, please call us to reserve an appointment. Phones open at

8:00am for scheduling.

*Gresham patients requiring Weekend Care will be seen at our Happy Valley Office.

Please contact us before going to an urgent care clinic or the ER! In most cases, we can treat your child in our clinic, saving you time and worry.

Locations 24988 SE Stark St., Ste. 200 Gresham, OR 97030 503-667-8878 9300 SE 91st Ave., Ste. 200 Happy Valley, OR 97086 503-261-1171 1130 NW 22nd Ave., Ste. 320 Portland, OR 97210 503-295-2546

15455 NW Greenbrier Pkwy., Ste. 111 Beaverton, OR 97006 503-531-3434 Hours Monday – Friday: 8:30 AM – 5:30 PM* Scheduling starts at 7:30 AM *Some clinics offer extended hours Saturday & Sunday:

Scheduling starts at 8:00 AM

www.metropediatrics.com

Rev. 05/29/2015

Give records to: Verbally exchange with: Request records from:

Name: ________________________________________________ Phone: (_____)____________ FAX: (_____)____________ Address: ______________________________________________________________________________________________

Street City State Zip Code

Email: _________________________________________ My medical information: MAY or MAY NOT be faxed.

MAY or MAY NOT be securely emailed.

Metropolitan Pediatrics accepts medical records via fax, secure email, or mail.

I authorize Metropolitan Pediatrics to (check all appropriate boxes, and provide complete name and address information):

By initialing spaces below, I specifically authorize the release of the following medical records if such records exist:

_______ Chart notes _______ Laboratory reports _______ ALL medical records

_______ Diagnostic imaging _______ Immunization records _______  Past 2 years

_______ Other: _________________________________________________________________________________________ Records containing the following information require additional consent (items must be initialed to be released):

_______ Mental health and ADD/ADHD diagnosis or treatment information _______ Genetic testing

_______ Drug/alcohol diagnosis, treatment, or referral information _______ HIV/AIDS testing

Patient Name: _____________________________________________ Date of Birth: ______/_______/_______

Please print full name.

Address: _____________________________________________________________________________________

Street City State Zip Code

Home/Cell Phone: (_________)____________________ Work Phone: (_________)____________________

Release Purpose: Self Changing provider Consultation  Legal Other: _________________

MY SIGNATURE INDICATES THAT I UNDERSTAND AND AGREE TO THE FOLLOWING:

I understand that the information used or disclosed in this authorization may be subject to re-disclosure and may no longer be protected under federal law. However, I also understand that federal or state law may restrict re-disclosure of HIV/AIDS test or result information, mental health information, genetic testing information, and drug/alcohol diagnosis, treatment, or referral information.

I understand that the person or entity I am authorizing to use and/or disclose information may receive compensation for doing so.

I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain health care services or reimbursement for services unless authorization is required to bill my insurance company. The only circumstance when refusal to sign means I will not receive health care services is if the health care services are solely for the purpose of providing health information to someone else, and the authorization is necessary to make that disclosure.

I understand that I may revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to:

I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: ________________________. If I fail to specify an expiration date, event, or condition, this authorization will expire 1 year from the date signed.

X__________________________________________ ________________________________________ X_______/________/_________

Signature of Patient/Parent/Legal Guardian Print Name | Relationship to Patient Date

X__________________________________________ ________________________________________ X_______/________/_________

Patients 14 years and older – SIGNATURE REQUIRED Print Name Date

Authorization to Release Medical Records • Page 1 of 2

Metropolitan Pediatrics, LLC

Authorization to Release Medical Records

HEALTH INFORMATION SERVICES

15455 NW Greenbrier Parkway, Suite 112, Beaverton, OR 97006 503-601-3417 • FAX 503-466-1858 • [email protected]

Rev. 05/29/2015 Authorization to Release Medical Records • Page 2 of 2

MEDICAL RECORDS COPY FEE:

As you may know, we are governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to protect patients’ rights to confidentiality, as well as to track and report each request. Therefore, in order to fulfill your request, we must ask for an upfront fee before copying. This fee will offset costs associated with copying, tracking, and reporting processes surrounding your request.

There is a flat copy charge of $20.00 for any personal request for medical record copies. Please make checks payable to Metropolitan Pediatrics. We will process your request when payment is received.

MAXIMUM TIME ALLOWED FOR COPYING MEDICAL RECORDS:

♥ Thirty (30) days if chart is maintained at the medical office.

♥ Sixty (60) days if chart is maintained off-site in medical records storage facility.

Payment Received: $ Date: / /

Metropolitan Pediatrics, LLC

Patient Information

Rev. 10/06/2014

CONSENT FOR TREATMENT: I authorize the physicians and clinic personnel of Metropolitan Pediatrics, LLC, to conduct physical examinations and routine services, order and perform tests, and administer treatment deemed necessary by the examining physician. Should treatment be performed, the physi cian will fully inform me as to the nature of the procedure, the alternatives to treatment, and the risks involved. I will be given the opportunity to ask questions and have m y questions answered. Should special procedures be indicated, I understand that the examining physician will discuss this with me and that additional consent(s) may be required .

FINANCIAL RESPONSIBILITY: I understand that I am responsible for all charges resulting from treatment provided by Metropolitan Pediatrics, LLC, as well as any agency and/or legal fees incurred should my account be placed in a collection status. I agree to pay the balance due within 30 days of stat ement billing unless I have made other payment arrangements.

ASSIGNMENT OF BENEFITS: I authorize my insurance carrier(s) to remit payment of benefits for any claim to Metropolitan Pediatrics, LLC. I understand that any ineligible or non-covered expenses are my responsibility.

I assign Metropolitan Pediatrics, LLC, as an Authorized Representative to: (1) Submit any and all appeals when my insurance c ompany denies me benefits to which I am entitled, (2) Submit any and all requests for benefit information from my insurance company, (3) Initiate formal complaints to any state or federal agency that has jurisdiction over my benefits, and (4) Release all medical information necessary to process my claims. I authorize any plan administrator or insurer to rele ase any and all plan documents, insurance policy, and/or settlement information upon written request from Metropolitan Pediatrics, LLC. This assignment is valid for all administrativ e and judicial reviews under PPACA, ERISA, Medicare, and applicable federal or state laws. A photocopy of this assignment is to be considered as valid as the original.

X__________________________________________ ________________________________________ X_______/________/_________

Signature of Patient/Parent/Legal Guardian Print Name | Relationship to Patient Date

Gresham ♥ 503-667-8878 Happy Valley ♥ 503-261-1171 Northwest ♥ 503-295-2546 Westside ♥ 503-531-3434 PARENT INFORMATION Name: _________________________________________ Last First MI SSN: _________________ DOB: / / M F

Marital Status: Married Single Divorced Widowed

Address: _______________________________________ City/State/Zip: __________________________________ Email: _________________________________________ Home: (_____)____________ Cell: (_____) ____________ How did you hear about us? _____________________

OTHER PARENT INFORMATION

Name: _________________________________________ Last First MI

SSN: ________________ DOB: / / M F

Marital Status: Married Single Divorced Widowed

Address: _______________________________________ City/State/Zip: __________________________________ Email: _________________________________________ Home: (_____)____________ Cell: (_____) ____________

Private Pay (no insurance)

Insurance (primary) Eff. Date: / /___

Insurance Co: __________________________________ Employer: ______________________________________ Policyholder: __________________ DOB: / /___ Policy #: _______________________________________ Group #: _________________ Copay: $ _____________ PATIENT INFORMATION New Patient? Y N Name: ________________________________________ Last First MI SSN: _________________ DOB: / / M F

OTHER CHILDREN IN FAMILY

Patient Here? Y N Name: ________________________________________ Last First MI SSN: _________________ DOB: / / M F ……..…………..Patient Here? Y N….……….…….. Name: ________________________________________ Last First MI SSN: _________________ DOB: / / M F ……..…………..Patient Here? Y N….……….…….. Name: ________________________________________ Last First MI SSN: _________________ DOB: / / M F

EMERGENCY CONTACT (other than spouse) Name: ________________________________________ Last First MI Relationship to Patient: _________________________ Home: (_____)____________ Cell: (_____) ___________

OHP (circle one): FamilyCare | OMAP

Insurance (secondary) Eff.Date: / /___

Insurance Co: __________________________________ Employer: _____________________________________ Policyholder: __________________DOB: / /___ Policy #: ______________________________________ Group #: _________________ Copay: $ _____________ BILLING INFORMATION

Metropolitan Pediatrics, LLC

Patient Intake Form

Rev. 06/30/2015

BIRTH HISTORY—Delivery/Newborn Period

Delivery Type:  Vaginal  C-section

Gestational Age: _________ Birth Weight: __________

Date hepatitis B given: ______/_______/_______

Problems in newborn period: ________________________ ___________________________________________________ ___________________________________________________

PATIENT SURGICAL HISTORY

 Adenoidectomy  C-section  Lymph node biopsy

 Appendectomy  Fracture surgery  Tonsillectomy

 Circumcision  Heart surgery  Ear tubes

 Cleft lip  Hernia repair  Umbilical hernia

 Cleft palate  Inguinal hernia  Undescended testicle surgery

 Cosmetic surgery

 Other: ___________________________________________________________________________________________

BIRTH HISTORY—Pregnancy Did mother…

...smoke?  Yes  No ...drink alcohol?  Yes  No

...use drugs/medications?  Yes  No

If yes, what kind(s)? _____________________________

...experience illness/complications?  Yes  No

If yes, what kind(s)? _____________________________

Patient Intake Form • Page 1 of 2 Patient Name: _____________________________________________ Date of Birth: ______/_______/_______ MR#: ____________________________________________________ Date of Service: ______/_______/_______

Welcome to Metropolitan Pediatrics!

Please take the time to fill out this form as accurately as possible so we can most appropriately address your child’s health needs. Thank you!

Gresham ♥ 503-667-8878 Happy Valley ♥ 503-261-1171 Northwest ♥ 503-295-2546 Westside ♥ 503-531-3434

 American Indian or Alaska Native  Asian  Black or African American  Hispanic

 Native Hawaiian or other Pacific Islander  White (non-Hispanic)  Other

MORE QUESTIONS ON THE BACK SIDE



PATIENT MEDICAL HISTORY

 ADD/ADHD  Hearing loss  Scoliosis

 Allergies  Heart murmur  Seizures

 Anxiety  Immune deficiency  Sickle cell

 Arthritis  Inflammatory bowel disease  Strep throat (recurrent)

 Asthma  Jaundice  Thyroid disease

 Cancer/Oncology  Meningitis  Tuberculosis

 Diabetes mellitus  Otitis media  UTI

 Eating disorder  Pneumonia  Varicella (chickenpox)

 Eczema  Prematurity  Vision problems

 Headaches

Rev. 06/30/2015 Patient Intake Form • Page 2 of 2 F A M IL Y H IST ORY H ave any fa m ily me mbe rs had t he fo llo w ing c o nd it io ns ? Pl ea se ma rk an ‘X’ by ea ch con d it io n tha t ap pl ies. F am ily M em be r N am e: Date o f B ir th:

Lives with patient? No Known Problems Other ADHD Allergy-Severe Arthritis Asthma Birth Defects Bleeding Problem Clotting Disorder Depression Developmental Delay Diabetes Early Death Eczema Hearing Loss Heart Defect Heart Disease High Blood Pressure High Cholesterol Kidney Disease Obesity Rheumatologic Disease Seizures Substance Abuse Sudden Death Thyroid Disease Vision Loss M o th er : / / F a th er : / / S ib lin g : / / S ib lin g : / / M a ter n a l Gm a : M a ter n a l G p a : P a ter n a l Gm a: P a ter n a l G p a : Oth er : / / Li s t any o ther con d it io ns ( by fa mi ly me mbe r) : ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ___ ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ___ ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ___ ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ____ _ ______ ____ ____ ____ ___

metpGPN#77

Genetic Privacy Notice

Notice of Your Right to Decline Participation in Future Anonymous or Coded Genetic Research

Metropolitan Pediatrics, LLC is required by Oregon law to provide this notice to you regarding the use of your health information or biological samples for genetic research (OAR 333-025-0100-333-025-0165). State law protects the genetic privacy of individuals and gives you the right to decline to have your health information or biological samples used for research.

A biological sample may include a blood sample, urine sample, or other materials collected from your body. You can decide whether to allow your health information or biological samples to be available for genetic research. Your decision will not affect either the care you receive from your health care provider or your health insurance coverage.

Research is important because it gives us valuable information on how to improve health, such as ways to prevent or better treat heart disease, diabetes and cancer. Under Oregon law, a special team reviews all genetic research before it begins. The team makes sure that the benefits of the research are greater than any risks to participants. In anonymous research, personal information that could be used to identify you, such as your name, Social Security number or medical record number, cannot be linked to you health information or biological sample. In coded research, personal information that could be used to identify you is kept separate from your health information or biological sample, making it very difficult to link your personal information to your health information or biological sample. Your identity is protected in both types of research.

If you DO NOT want to have your health information and biological sample available for anonymous or coded genetic research, YOU MUST tell your health care provider by checking the box below, signing and returning the form as directed by your clinic representative.

GENETIC PRIVACY OPT OUT STATEMENT

q

I have read and understand the above Genetic Privacy Notice and I DO NOT want to have my

health information and biological samples available for anonymous or coded genetic research.

Today’s Date _________________________

Patient Name (PRINT) ____________________________________________ Patient Date of Birth __________________ Patient or Personal Representative (Signature) ____________________________________________________________ If signed by Personal Representative, Describe Authority or Relationship to Patient _____________________________

If you want to allow your health information and biological sample to be available for anonymous or coded genetic research and make this choice, your health information or biological sample may be used for anonymous or coded genetic research without further notice to you.

No matter what you decide now, you can always change your mind later by completing this form and returning it to your health care provider. Your new decision is effective on the date your health care provider receives the Genetic Privacy Opt Out form, and will apply only to health information or biological samples collected after your health care provider receives the form. If you have questions about Genetic Testing, please call the Oregon Genetics Program at 971-673-0271.

This form will be retained in your medical chart throughout your relationship with Metropolitan Pediatrics, LLC. Sincerely,