Developmental-Behavioral Pediatrics, Please Arrive 15 Minutes Prior To

Developmental-Behavioral Pediatrics 8402 Harcourt Road, Suite 105 Indianapolis, IN 46260-2006 317-582-8290 PHONE 317-582-8291 FAX stvincent.org/peytonmanning Welcome to Developmental-Behavioral Pediatrics, Please arrive 15 minutes prior to your scheduled appointment in order to complete the registration process. Being late for your appointment might mean we will need to reschedule your appointment. Your appointment is a Consultative Visit to become acquainted and for us to determine how your child's needs may best be met. Enclosed you will find a Patient Information Packet which we ask you to review as soon as possible. This packet contains registration material, directions to our office, patient history forms and forms that must be completed by your child's school. It is very important that you return the forms to our office prior to your appointment or bring to the office the day of the appointment. Having this information will allow us to address your concerns and provide recommendations in a more complete and efficient manner. Please bring the following items with you to this appointment: • Completed Patient Information Packet • Insurance cards • Driver's license or ID of parent/guardian • Any other past medical, mental health, therapy, testing and school information pertaining to this appointment which you believe would be helpful Please know that it is required by law that all children under the age of 18 must be present with a legal guardian unless written authorization is provided. The appointment is scheduled to last 60-90 minutes. If you need to cancel or reschedule your appointment, please call our office at least 24 hours in advance so we may offer this time to another family. We look forward to meeting you and your child. Please contact us if you have any questions. Sincerely, Developmental-Behavioral Pediatrics 2/2016 Patient Demographic Information Form Please fill out every space. If it does not pertain to you, please write N/A, for Not Applicable. Patient Information Patient’s Name (Last, First, Middle) (Suffix) (Preferred) (Former Last Name) If patient is a child, Parent’s Names Sex Date of Birth Social Security # Marital Status: ❑ Married ❑ Single ❑ Divorced ❑ Male ❑ Female ❑ Widowed ❑ Separated ❑ Partner Address City State Zip code Home Phone Mobile Phone Work Phone Patient Email Preferred Languag e Race Ethnicity ❑ Hispanic ❑ Non-Hispanic Provider Information Primary Care Physician Referring Provider Communication ❑ I authorize St.Vincent, and those parties acting on behalf of St.Vincent, to contact me about appointments and reminders for health services via: ❑ Home Phone ❑ Mobile Phone ❑ Email Is it OK to leave medical information on your answering machine or voice mail? ❑ Yes ❑ No Guardian Name (Last, First, Middle, Suffix) Emergency Contact Information Name Relationship Home Phone # Mobile Phone # Employment Employer’s name Phone Address City State Zip code 2 SVPP Forms/Patient Demographics (7/15/2015) Page 1 of 2 WB-2BB Guarantor Patient’s Relationship to G uarantor Name (Last, First, Middle, Suffix) Date of Birth Address City State Zip code Employer Social Security # Insurance Primary Insurance Company Subscriber’s Name (Policyholder) Subscriber’s DOB Relationship to Subscriber Secondary Insurance Company Subscriber’s Name (Policyholder) Subscriber’s DOB Relationship to Subscriber Clinical Information Preferred Pharmacy Preferred Lab Financial and Treatment Consent By signing my name below: • I hereby guarantee payment in full within thirty (30) days of all charges established by St.Vincent Health for services rendered to me or my dependent, unless other arrangements satisfactory to St.Vincent Health have been made. This includes any charges that a third-party payer may determine to exceed usual and customary limits. • I understand and acknowledge that if any unpaid amounts owed by me are assigned to a third party for collection, I will be responsible for paying attorney fees, interest, court costs, and other costs of collection, including but not limited to collection agency fees. • I authorize Medicare, Medicaid, all relevant commercial payers to pay St.Vincent Health on my behalf for any services furnished to me or my dependent. I certify that I have read this assignment of benefits, that the information given by me is correct, and that I agree to all of the provisions contained in it. • I understand that if I am facing financial difficulty I can apply for financial assistance from St.Vincent Health. • The insurance information I have provided is current and correct. If I sign this form and the insurance card is found later to be outdated or invalid, I understand that I am responsible for paying for the services in full and will need to file with the insurance carrier myself. • I hereby consent to treatment by my St.Vincent Health Provider(s). I understand that St.Vincent Health will release to my referring or subsequent healthcare provider, reports of my medical condition that will assist him or her in my continuing care and as needed to process claims and for general health care operations. I agree that this Consent is valid for all treatment and payment of said treatment for a period of twelve (12) months following execution of the Consent. • I understand my insurance co-pay is due at the time of service, per my insurance company policy. I ACKNOWLEDGE RECEIPT OF THE NOTICE OF PRIVACY PRACTICES:_____________(Patient’s Initials) Patient/Guarantor/Guardian Signature Date **OFFICE USE ONLY** NPP Witness/Issued by: ________________________________________________________ 2 SVPP Forms/Patient Demographics (7/15/2015) Page 2 of 2 WB-2BB DEVELOPMENTAL -BEHAVIORAL PE D IATRICS HISTORY FORM 8402 Harcourt Road, Suite 105 Indianapolis, IN 46260-2006 Tel: (317) 582-8290 • Fax: (317) 582-8291 Child’s Name ____________________________ Birth Date ___________________ Child’s Nickname _________________________ Please feel free to use the backs of these pages to further explain answers, if needed. I. PURPOSE OF EVALUATION What are your questions or concerns regarding your child? II. PREGNANCY AND BIRTH HISTORY This section is to be completed by the mother of the child, if possible. Please indicate if answered by another person: _________________. Number of pregnancies you have had __________ Number of live births __________ Number of stillbirths __________ Number of miscarriages __________ Number of living children __________ Number of deceased children __________ This child was the product of pregnancy number __________ Page 2 Child’s Name __________________ Yes No Do Not Know Comments Did you have any health problems during pregnancy with this child? If yes, please describe the problem and the time it oc- curred during the pregnancy (such as infections, high blood pressure, diabetes, bleeding, weight loss, accidents, fever, etc.) Did you take any medication, smoke, drink, or use drugs during this pregnancy? If yes, please list. Was your baby carried a full nine months? If no, please indicate length of the pregnancy. Were there any difficulties with delivery? If yes, please describe the problems (such as Cesarean section, slow heart rate, fever, etc.) How much did your baby weigh at birth? ______ pounds, ______ ounces Did your baby need any special care during the first few days after delivery? If yes, please describe. Did you have any difficulty caring for your child during the first few months of life? If yes, please describe. III. PAST AND PRESENT HEALTH HISTORY Yes No Do Not Know Comments Has your child ever been hospitalized? If yes, please describe, including child’s age. Has your child ever had any serious accidents requir- ing medical care? If yes, please describe, including your child’s age. Does your child have any serious or chronic illnesses? Please describe. Has your child ever had a seizure or convulsion? If yes, please describe, including child’s age. Has your child ever had tics? (Facial movements, eye- blinking, vocalizations, etc.) Has your child ever had heart problems? If yes, please describe. Page 3 Child’s Name __________________ Yes No Do Not Know Comments Is your child presently taking any medication, herbals, or vitamins? If yes, please list the medications, dosages, and why. Does your child have any known allergies? Please describe. Do you feel your child has trouble hearing? If yes, please explain. Do you feel your child has trouble seeing? If yes, please explain. Has your child been or is your child now on a special diet? If yes, please describe. IV. DEVELOPMENTAL HISTORY Yes No Do Not Know Comments Was your child’s development any faster or slower than that of other children? Please explain. At what age did your child sit alone? At what age did your child crawl? At what age did your child walk alone? At what age did your child make sounds? At what age did your child say single words? At what age did your child combine words? Is your child toilet trained? If yes, age what age? Does your child have toileting accidents during the day? If yes, how often? Does your child have toileting accidents during the night? If yes, how often? Page 4 Child’s Name __________________ Please describe what toys or activities your child enjoys: Describe your child’s interactions with family members and other children: Please describe what your consider to be your child’s strengths: Has your child received or been evaluated for any of the following? Yes No Date Educational Psychological Testing Speech/language therapy Physical therapy Occupational therapy Tutoring Individualized and/or Family

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