Barbara A. Aquino M.D., PLLC, 881 Professional Park Drive, Clarksville, TN 37040

Barbara A. Aquino M.D., PLLC, 881 Professional Park Drive, Clarksville, TN 37040 Patient Information Sheet

Date______Race______Ethnicity ______Spoken Language______

Whom does your child primarily reside with? ______

Child Information Last Name______First Name______MI______Male/Female

Social Security______Date of Birth______Child’s Father (Custodial) Last Name______First Name______MI____Home Phone______

Street Address______Work Phone______

City______State______Date of Birth______

Zip Code______Cell Phone______Social Security #______

Employer/School______Email ______Marital Status______

Child’s Mother (Custodial) Last Name______First Name______MI______Home Phone______

Street Address______Work Phone______

City______State______Date of Birth______

Zip Code______Cell Phone______Social Security # ______

Employer/School______Email______Marital Status______

Primary Pharmacy Used______Phone #______

Please list the Hospital where your child was born:______

Please list ALL Insurance Information and let us copy your insurance card(s). Insurance Information (Primary) Insurance Information (Secondary)

Name of Insurance______Name of Insurance ______

Insurance ID #______Insurance ID #______

Group # or Group Name______Group # or Group Name______

Guarantor Name______Relationship to Patient______(Person financially responsible) Phone #______

Emergency Contact______Relationship to Patient______(Closest relative or friend NOT living with you) Phone #______

Please circle if included: Divorce Decree Custodial Paperwork Birth Certificate

Barbara A. Aquino M.D., PLLC 881 Professional Park Drive Clarksville, TN 37040

1. I certify that to the best of my knowledge the information on previous page is correct. 2. I authorize Barbara A. Aquino M.D., PLLC to review my insurance coverage with my insurance company as indicated. 3. I authorize Barbara A. Aquino, M.D., PLLC to release medical and other information to my insurance company for review of my coverage and/or for the processing of claims for services rendered on my dependents. 4. I further authorize the release to Barbara A. Aquino M.D., PLLC of such information as may be necessary for the purpose by my insurance company. 5. I permit a copy of this authorization to be used in place of the original. 6. I hereby authorize my insurance company to pay directly to Barbara A. Aquino M.D., PLLC benefits due me out of my indemnity under the terms of my policy issued by your company. 7. I understand that my insurance carrier may pay less than the actual bill for services and I agree to be responsible for payment of ALL services rendered on my dependents. 8. The undersigned agrees that all services are rendered on a paid basis only. If collection becomes necessary, the undersigned shall pay all costs including attorney’s fees. 9. I authorize Barbara A. Aquino M.D., PLLC to release copies of medical records to other medical providers who I may be referred to, to further my care. 10. I understand that if my insurance coverage is with a contracted carrier that I agree to be responsible for any copay, coinsurance, deductibles, and other non-covered services; some payment will be required at time of visit. 11. I understand that any insurance not provided to Barbara A. Aquino M.D., PLLC at the time of visit may not be filed and guarantor will be responsible for the visit. 12. If my insurance company is a HMO plan, I understand that my child’s PCP must be Barbara A. Aquino, M.D. at the time of visit. 13. I understand that I must provide Barbara A. Aquino, M.D., PLLC with both mother and father information on this paperwork however in the case of divorce, custodial or guardianship changes or residency with someone other than natural parents; one of the following must be provided to this office, divorce decree, custodial paperwork or birth certificate. 14. I consent to allow Dr. Barbara A. Aquino, M.D., PLLC to access my child’s prescription history when integral to my child’s health care or deemed medical necessary.

Signature______Date______

Medical Release

Patient Name______Date of Birth______Last First MI

Street Address______City______State______Zip ______

Parent/Guardian Signature______Date______

Please release records: TO / FROM Barbara A. Aquino M.D. 881 Professional Park Drive Clarksville, TN 37040 Phone (931) 645-4685 Fax (931) 245-2117

Reason for Release______

Physician Name______Phone # ______

Address ______Fax # ______

This authorization expires upon the patient attaining the age 18. This authorization applies to any information, including personal health information, and to any class of persons necessary for treatment or health care operations purposes. Subject to prior disclosures, the patient (or patient’s authorized representative) may revoke this authorization by notifying Dr. Aquino in writing. Information disclosed may be re-disclosed and no longer protected by federal privacy regulations.