Forms

Demographics 2025 Information to bring to your appointment
Change of Insurance
Prenatal Visit
HIPPA Acknowledgement
Change of Address
Pre Circumcision form
Medical Record Release
After Care for Circumcision

Cancellation Policy

If you're unable to make your appointment,

please call or email our office 24 hours prior

to your appointment to avoid no show fees.

Reminder

All medical appointments must have a parent or designated caregiver and child/patient present during the office visit to be seen by a medical provider.
Thank you for your understanding.

Reminder

National Shortage of Stimulant Medication at local pharmacies. Parents are kindly asked to work with their local pharmacies to assist our providers who are required to electronically prescribe and properly monitor the allocation of these mediations.

Step 1 of 12

Child 1:

First Name Last Name

DOB

MM slash DD slash YYYY

Sex

Primary Language

Do you need an interpreter?

Yes

Ethnicity

Hispanic

Non-Hispanic

Unknown Race

Asian

Black

Hawaiian

White

Allergies to Medications1

Yes

None

Allergies to Medications

Food/Seasonal Allergies1

Yes

None

Allergies to Medications

Child 2:

First Name Last Name

DOB

MM slash DD slash YYYY

Sex

Primary Language

Do you need an interpreter?

Yes

Ethnicity

Hispanic

Non-Hispanic

Unknown Race

Asian

Black

Hawaiian

White

Allergies to Medications2

Yes

None

Allergies to Medications

Food/Seasonal Allergies2

Yes

None

Food/Seasonal Allergies

Child 3:

First Name Last Name

DOB

MM slash DD slash YYYY

Sex

Primary Language

Do you need an interpreter?

Yes

Ethnicity

Hispanic

Non-Hispanic

Unknown Race

Asian

Black

Hawaiian

White

Allergies to Medications3

Yes

None

Allergies to Medications

Food/Seasonal Allergies3

Yes

None

Food/Seasonal Allergies

****PLEASE ASK FRONT DESK FOR ANOTHER SHEET FOR ADDITIONAL CHILDREN****

Email Address

Mother/Guardian Info

Name

Relation to patient

Lives with patient

Yes

Date of birth

MM slash DD slash YYYY

Address

Street or PO Box Apt/Unit No. City State ZIP

Cell phone

Work phone

Employer

Occupation

Father/Guardian Info

Name

Relation to patient

Lives with patient

Yes

Date of birth

MM slash DD slash YYYY

Address

Street or PO Box Apt/Unit No. City State ZIP

Cell phone

Work phone

Employer

Occupation

How would you ideally prefer to be contacted regarding the following (check only one):

Medical Issues

Home phone

Work phone

Cell phone

May we leave voicemail

with detail

without detail

Emergency Contact

Name

Relation to patient

Address

Street or PO Box Apt/Unit No. City State ZIP

Cell phone

Work phone

Insurance:

Primary policy:

Insurance Company

Address

Insurance Street or PO Box City State ZIP

Policy’s holder’s name

Policy holder’s date of birth:

MM slash DD slash YYYY

ID#

Group#

Secondary policy:

Insurance Company

Address

Insurance Street or PO Box City State ZIP

Policy’s holder’s name

Policy holder’s date of birth:

MM slash DD slash YYYY

ID#

Group#

Pharmacy:

Name of Pharmacy

Telephone #

Address

Additional Contact Questions

Who should receive billing statements?

(If it should be a person other than the one completing this form, please provide legal documentation supporting this claim)

If parents are divorced or separated, please fill out this section

Who has custody?

Are there any legal restrictions that would restrict the non-custodial parent from consenting to medical treatment for the child or from obtaining information about the child’s medical treatment?

Yes

If yes, please provide a copy of any legal paperwork that supports this restriction.

Max. file size: 100 MB.

SIENA PEDIATRICS OFFICE POLICIES

Effective January 1, 2021, Patient refunds are no longer being reimbursed. They will be applied towards your child’s account. We will deduct any copays, coinsurance, deductibles, or any other charges your insurance carrier may apply towards your responsibility.
Government issued ID and insurance cards are to be presented at EVERY visit. If your insurance card isn’t provided and we cannot verify your insurance, your appointment will be treated as cash pay. All services will be due at time of service.
Your insurance policy is a contract between you, your employer, and your insurance company. We are not a party to that contract. Our relationship is with you and you are ultimately responsible for any service provided, regardless of your insurance coverage.
If you have Managed Care insurance, please make sure you have contacted them and select us as your primary care physicians or you will be responsible for payment of services.
Our practice is contracted with various insurance companies, it is your responsibility to contact your insurance if we are contracted providers. Our billing department only verifies if your insurance is active and if any copays, co-insurances, and/or deductibles is applied towards your visit.
All balances are due at check in, this will include copays, co-insurances, and/or deductibles. If you are unable to pay, you may ask to speak with our billing department to setup promissory note.
We bill your insurance as a courtesy, not all services are covered by your insurance company. It is your responsibility to know what is covered and what is not.
If any charges incurred by you or your dependents are submitted to a collection agency, you agree to pay all fees including, but not limited to, both collection agency fee and the account balance. Once account has gone to collections, we cannot waive the collection agency’s fees.
In efforts to see all pediatric patients needing urgent medical care, we ask that you arrive to appointment 10 minutes early. Your appointment may be cancelled after 10 minutes.
To help deliver optimal healthcare and availability to our patients, we require 24 hours’ notice, so we can schedule another patient who needs medical care. If appointment isn’t cancelled, you will be assessed a $35 penalty fee.
If you incur 3 No Show appointments within a calendar time period, you will be discharged from our practice, however there will be a 30 days’ grace period for sick visits only. You will also be assessed a $50 penalty fee.
You agree to pay $35 returned check fee, in addition to the amount of the check, on any of your personal checks which are returned to this office by our bank.
While your appointment may be for a specific time, no express or implied guarantee is made that a nurse or physician will see you at the exact time. Siena Pediatrics makes every effort to see patients in a timely fashion, subject to patient volume and emergencies beyond our control. You agree not to hold Siena Pediatrics responsible in any manner for time spent waiting to be seen.
If your insurance has not paid within 180 days, you agree to pay all charges which have been incurred by you or your dependents at the time of visit, regardless of your insurance company’s instructions.
ALL medical record requests will take 7-10 business days, and photo ID must be provided during pick up. We will assess $25 charge for FMLA paperwork.
Walk in appointments you will be charged an extra $35 towards your visit.
If you need paperwork to be expedited, you will be charged $35 fee.
If there is any change of insurance, it is the parent/guardian’s responsibility to notify Siena Pediatrics of the changes.
For all newborns, parents are responsible to add child within first 30 days post birth. If child is not added within this time period, your visits will be treated as cash pay and/or all balances due will be parent’s/guardian’s responsibility.
As the child’s parent/guardian, I understand that it is my responsibility to make and attend all follow up visits ordered by the doctor. I understand the doctor would not order a follow up visit if it weren’t important. I also understand that Siena Pediatrics cannot call me and remind that I need to make a follow up appointment. Therefore, it is my responsibility if I should fail to schedule or attend a follow up visit.
I understand I am fully responsible to make and attend my appointments when referred to a specialist. I accept all responsibility if I fail to schedule or attend appointment with a specialist.
You agree and understand any damages to Siena Pediatrics facility, equipment or property by you, your child, or associated party will be financial responsibility. Any damages or destruction incurred to Siena Pediatrics will result in recuperation of reparation costs and could be subject to termination from the practice.

Parent/Guardian Signature

Date

MM slash DD slash YYYY

IMPORTANT INFORMATION

We collect all co-payments at the time services are rendered. A monthly statement will be sent to you detailing unpaid charges, if you have questions regarding items which have not been paid by your insurance, we ask that you call your insurance company, as benefit packages vary by insurance policy.

Our office bills are for doctor services only. Fees for lab work or cultures are billed separately by the appropriate lab.

Methods of Payment We accept MasterCard, Visa, American Express, Discover and debit card. It is the parent’s responsibility to know details of their insurance plan, its benefits, and the amount of the co-payment.

Recording Devices in Exam Rooms During your appointment, we kindly request you refrain from using any type of recording devices due to privacy of our patients and employees.

Effective Immediately!!!! New Vaccination Policy!!!! Our practice strongly believes in administering childhood vaccination for diseases prevention. In support of our beliefs and for the health and well-being of our patient population, we are not accepting new patients to the practice who do not comply with the minimum recommended vaccines.

Important Do not call from a phone that does not accept blocked calls, as physicians will be calling from a phone with a blocked number. Also, please do not call for routine calls after hours (such as a dose of medication), please respect our physicians’ time with their families. These calls are subject to change. For any urgent care issues that occur after midnight, patients are encouraged to be seen by a health professional.

In Case of Emergency If your child is experiencing a life-threatening emergency, please call 911 for immediate help. Urgent problems during regular office hours can be handled by contacting the office during our business hours. Notify the staff member who answers the phone that you have an urgent problem, and your call will be handled immediately. The physicians can be reached for urgent problems after hours by calling our answering service at 702-248-7337 and the service will page the physician on call. The provider will then return your call at the number you provide.

PLEASE SIGN BELOW TO ACKNOWLEDGE AND UNDERSTAND OUR POLICIES.

Parent/Guardian Signature

Date

MM slash DD slash YYYY

Insurance & Billing for Well Visits

Good healthcare for infants, children, and adolescents begins with the well child visit (checkup) and other services that keep children healthy. These are called preventative services. Our providers and staff provide the services based on called Bright futures. The American Academy of Pediatrics (AAP) made this plan to help doctors and families know which preventative services should be received from birth to 18 years of age, such as screening test is like developmental screenings for our younger patients and visions and hearing test for those 4 years old and older. We also followed the AAP vaccine schedule for newborns, infants, children, and adolescents.

Health Plans Terms to Know Co-payment: A fixed amount that you pay for certain health services before the plan pays

Co-insurance: The portion of the charge that is not paid by the health plan (usually a fixed percent of each amount paid by the plan)

Deductible: An amount that must be paid before the health plan pay for covered services.

There may also be times when a child needs a service that is not considered preventative on the same day as a well child visit. If a child is not well or if a problem needs to be addressed during the checkup, the provider will need to provide an additional office visit service (called a sick visit) to care for the child. This is a different service and is required to be billed to your insurance and in addition to the preventative services provided on the same day. If you have a co-payment, co-insurance, or deductible amount for the sick visit, you will be responsible for the services, our office must charge you these amounts in accordance with the contract we have with your health plan.

We value your time and want to make the most of each appointment for a child. Therefore, we offer the opportunity to address any problem that needs a providers’ care during well child visits so only one trip is needed. Some examples of services that may be provided and billed in addition to preventative services include:

The providers work to address more than a minor problem, which must be billed has an office visit (For example, if the doctor gives a prescription, orders test, or changes care for a known problem) Medical treatments (For example, breathing treatments)

Any procedure (For example, strep, RSV, influenza tests, removing sutures, ear wax, or foreign body removal)

All well visits, 3 years and up will automatically include a vision screen. If your insurance does not cover this type of screening it is your responsibility to let the office know in writing before the procedure is done, please notify the office if you do not want the vision done on a child.

Our office does not want you to be surprised by a bill, but we must always bill your health plan based on the actual charges provided. Please feel free to ask questions about services that may not be paid in full by your health plan on the day of your visit.

Parent/Guardian Signature

Date

MM slash DD slash YYYY

Authorization Non-Parent/Guardian to Accompany Patient

Periodically there may be times when you are unable to bring your child to the office for an appointment and need to rely on a family member or friend. We understand these circumstances; however, we must have a written authorization letter allowing this person to accompany your child(ren). The person brings your child will need to present a photo identification at time of service.

This authorization gives the person permission to bring your child(ren) in, speak to the doctor, given authorization for treatment, vaccinations, medication, certain procedures and make general health decisions.

I, ____________________________________, give the person(s) listed below permission to bring my child to Siena Pediatrics and to discuss and share medical information about my child. I further authorize them to see all necessary medical records and make health care decisions of a routine nature as determined at the sole discretion of the Siena Pediatrics provider/staff.

I also give them authority to make more serious or urgent health care decisions in the event I cannot be reached or where it is of an emergency nature where there is not sufficient time to seek out my specific consent.

Child’s Name:

DOB

MM slash DD slash YYYY

Child’s Name:

DOB

MM slash DD slash YYYY

Child’s Name:

DOB

MM slash DD slash YYYY

(IF ONLY PARENTS ARE ALLOWED TO BRING CHILD IN, PLEASE INDICATE ‘NONE’)

Name of Person (allowed to bring child)

Relationship

Name of Person (allowed to bring child)

Relationship

Parent/Guardian Signature

Date

MM slash DD slash YYYY

PATIENT CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS IN ACCORDANCE TO HIPAA

I ____________________________________________, understand that as a part of my child’s health care, Siena Pediatrics originates and maintains paper and/or electronic records describing my child’s health history, symptoms, examinations, test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information serves as:

A basis for planning my care and treatment
A means of communication among the many health professionals who contribute to my care
A source of information for applying my diagnosis and surgical information to my bill
A means by which a third-party payer (s) can verify that services billed were actually provided
A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

The right to review the notice prior to signing this consent/disclosure
The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations

I understand that Siena Pediatrics is not required to agree with the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me permitted by Section 164.520 of the Code of Federal Regulations.

I understand that as part of this organization’s treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity (Insurance company, referring physician, consulting physician, hospital, etc.), and I consent to such disclosure for these permitted uses, including disclosures via fax or email.

In addition, I also give consent to Siena Pediatrics to disclose my protected healthcare information to the following person and/or people:

Name

Relationship

Name

Relationship

Name

Relationship

I fully understand and accept the terms of this consent.

Date

MM slash DD slash YYYY

ACKNOWLEDGEMENT OF OUR NOTICE OF PRIVACY PRACTICES

I hereby acknowledge that I have received or have been given the opportunity to receive a copy of Siena Pediatrics Notice of Privacy Practices. By signing below, I am “only” giving acknowledgment that I have received or have had the opportunity to receive the Notice of our Privacy Practices.

Child’s Name:

DOB

MM slash DD slash YYYY

Child’s Name:

DOB

MM slash DD slash YYYY

Child’s Name:

DOB

MM slash DD slash YYYY

Parent/Guardian Signature

Date

MM slash DD slash YYYY

Comments

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