New Pediatric Intake Forms – Lifestages OBGYN

If you have not already scheduled an appointment, please call the office at (208) 442-8035 to schedule

This form does not prompt scheduling of your intended appointment

Patient Information

Name *

First

Last

Email Address *

Emergency Contact Name

Emergency Contact Number

Date of Birth *

Gender

Phone Number *

Guardian (If Applicable)

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Insurance Coverage

Primary Insurance Name

Subscribers Date of Birth

ID/Policy Number

Group Number

Subscriber Name

Secondary Insurance Coverage

Secondary Insurance Name

Subscribers Date of Birth

ID/Policy Number

Group Number

Subscriber Name

Pharmacy

Primary Preferred Pharmacy

Secondary Preferred Pharmacy

Online Portal

Would you like to be Web-enabled in our system?

Allows you to view lab results, balances accrued, receive appointment reminders and access your medical records through our clinics patient portal.

Past Medical History (PMH)

Has your child ever been diagnosed with the following:

Asthma or airway disease
Wheezing or bronchiolitis
Seasonal allergies or eczema
Food allergies
Recurrent ear infections
Jaundice
Pneumonia
Urinary tract infections
A genetic syndrome
Seizures
Anemia
Broken Bones
Cancer
Learning disability
Depression/anxiety

Additional Medical History

Surgical History

Medications

Allergies

Pediatric Demographics

Patient Name

Patient Date of Birth

Relationship to the patient:

Childs parents are:

For Newborns

Where was your child born?

Delivery Type

Any delivery complications?

Birthweight

Feeding

Do you plan to vaccinate?

Yes
No
Partially
Undecided

For School-Age Children

School Name

Do you plan to vaccinate?

Yes
No
Partially
Undecided

Grade Level

Family History

Mother

Father

Siblings

Social History

Alcohol Use

Exercise

Tobacco Use

Recreational Drugs

Review of Systems (ROS)

Patients are often asked to check any symptoms they currently have or have had in the last 6-12 months.

Respiratory

Shortness of Breath
Cough
Wheezing
Chest Tightness
Hemoptysis (coughing up blood)

Neurological

Headaches
Dizziness
Seizures
Numbness or tingling
Memory loss or confusion

Endocrine

Excessive thirst
Excessive hunger
Heat or cold intolerance
Weight gain or loss
Fatigue

Genitourinary

Painful urination
Frequent urination
Blood in urine
Sexual dysfunction
Menstrual irregularities (for females)

Musculoskeletal

Joint pain
Muscle pain
Back pain
Swelling in joints
Limited range of motion

Dermatological

Rashes
Itching
Dry or oily skin
Acne or skin eruptions
Moles with changes in size, shape, or color

Psychiatric

Depression
Anxiety
Mood swings
Hallucinations or delusions
Sleep disturbances

Cardiovascular

Chest Pain
Palpitations
Shortness of breath
Leg swelling or edema
History of fainting or syncope

Regulatory

As part of national healthcare quality and equity initiatives, we are asked to collect information about your race, ethnicity, preferred language, and other demographic details. This information helps us ensure that all patients receive high-quality care and allows us to better understand and address the needs of the communities we serve.

Providing this information is voluntary and will not affect your care. Your responses are kept confidential and used only for quality improvement and reporting purposes in compliance with federal and state regulations.

Race

Ethnicity

Language

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan, and direct my treatment and follow-up among the multiple Healthcare providers who
may be involved in the treatment directly and indirectly
Obtain payment from third-party payers
Conduct normal healthcare operations such as quality assessments and physician certifications

I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that LIFESTAGES has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

Patient Name *

First

Last

Relationship to patient (if not self)

Signature *

Clear Signature

Date

Contact/Records Approval

It is our policy to keep all matters regarding our patients in strict confidence. Please take a few moments of your time to provide us with the names of your family and/or friends who may call in for information regarding your appointments, results, or any other medical information.

I authorize the following individuals to obtain information for/about me:

Name

First

Last

Name

First

Last

Name

First

Last

Name

First

Last

By checking below, you indicate that you do not authorize anyone to obtain your information at this time

I do not authorize the release of my information

Signature *

Clear Signature

Date

Birth Allergies Initials

Office Policies

We would like to take this opportunity to welcome you to LIFESTAGES.

Your clear understanding of our policies is important to our relationship. Therefore, please read carefully and feel free to ask any questions you may have.

Our office hours are: Monday-Thursday 8:30am-5:00pm

If you have an emergency after hours that cannot wait until normal business hours, please call our office and an operator will page the provider on call. Otherwise, please hold non-emergent matters until regular office hours.

Please check after reading each policy-regardless of applicability, unless otherwise noted

Clinic Policies:

Initials

Refill Requests-please give at least 24-hour’s notice on all refills. Contact your pharmacy first, and they will contact us with your needs. Refills will be authorized only during regular office hours. Narcotics (controlled medications) will not be filled after clinic hours, and can only be filled by your primary physician. Please do not wait until you are completely out of a medication before calling for a refill.

Initials

We require 24 hours’ notice if you are unable to make your scheduled appointment with your provider. We understand that circumstances arise when you are unable to do so, but we ask that you do your best to provide adequate notice. Our office No Show fee is $26 for missed appointments or cancellations with less than 24 hours notice

Initials

Service/Emotional Support Animals are welcome in the office. Animals must be in control at all times

Initials

Parental consent is required for ALL medical services provided to patients under the age of 18, in accordance with Idaho Senate Bill No. 1329, effective July 1, 2024. Therefore, a parent or guardian must accompany minors for all appointments, or sign a consent form ahead of time that patient must present at check-in

Initials

If you are not seen by a provider at our office for more than 3 years, you will be classified as a New Patient when rescheduling and subject to appointment availability and charges as such.

Initials

If you are needing our office to complete FMLA/Short Term Disability paperwork on your behalf, please bring in ALL required forms for your employer/insurance at the same time. Multiple sets of paperwork brought in after the initial set may result in a $25 processing fee to be paid before completion of the forms

Initials

As a courtesy, we bill your insurance for you. However, it is your responsibility to follow up with your carrier if the claims are not paid. Our billing staff will be happy to assist you with any questions. If payment is not received by insurance, the balance will become your responsibility

Initials

We require a copy of your current insurance card to ensure accurate billing. Please keep in mind: We do not accept all insurances. It is your responsibility to confirm directly with your insurance company to find out whether we participate with them and if they will cover the services being provided to you. If your insurance requires a referral, it is your responsibility to ensure this is in place at the time of service. Failure to do so will lead to rescheduling your appointment.

Initials

Balances need to be paid within 90 days of receiving your first statement. Unpaid balances will be reviewed and sent to Bonneville Management Service, for payment arrangements, or Bonneville Collections, which ever applies

Initials

Some insurance companies bill labs through our clinic, and some do not. If your insurance does not bill through us, you will receive a charge from and pay directly to the lab company. Please ask our staff for list of insurances that bill directly to patients if you are interested

Initials

All Self Pay Patients (no insurance) will be required to pay in full at the time of service, unless a payment plan has been arranged with our billing manager. We offer a 20% discount on most services for uninsured patients. For your convenience, our staff can give an estimate of charges for your appointment, but these quotes are not exact

Initials

All surgeries will be pre-certified prior to admission and the insurance company will quote benefits. Your co-insurance percentage is required 5 days prior to admission. The remaining balance will be set up on a monthly payment plan to be paid off no later than 3 months from the surgery date

Initials

Patients with NO insurance and needing surgery are required to pay half of the total surgery amount 2 days prior to surgery. The remaining balance will be set up on a payment plan or with Bonneville Management Service

Initials

If our office does not receive the required down payment by the above deadlines, your surgery may be postponed until payment is made

Initials

Medicaid patients on the Healthy Connections Program are be responsible for arranging referrals ahead of the appointment time. If referral from your listed Primary Care Physician is not received by our office at least 24 hours before your scheduled appointment time, your appointment will be rescheduled.

Initials

Your Medicaid ID number and/or card must be provided at time of service. Any charges that are accrued before Medicaid is active are the responsibility of the patient

Initials

Medicare only pays for routine physicals every two years. Please be aware that you may be billed for your exam or any other charges accrued from an annual physical visit if coverage is denied by Medicare

I request that payment of authorized insurance benefits be made, on my behalf, to LifeStages for any services furnished to me by that provider. I authorize any holder of medical information about me to release to the Council on Medical Service and its agents any information needed to determine benefits or the benefits payable for related services. This authorization is in effect until I choose to revoke it.

I understand that I am responsible for all charges regardless of insurance coverage, and I have read and understand the financial policies of LIFESTAGES.

Signature *

Clear Signature

Date

Missed Appointment Policy

To provide the highest quality care, it is necessary for patients to attend their scheduled appointments on time. As a courtesy, an appointment reminder will be sent prior to your scheduled appointment. However, it is the responsibility of the patient to arrive for their appointment on time, regardless of prior notification. If you are unable to keep your appointment, please notify us as soon as possible. We understand that occasional missed appointments can occur for a variety of reasons.

A “No Show/Late Cancellation” is defined as missing an appointment without cancelling at least 24 hours before the scheduled time. There will be a charge for a missed or late-cancelled appointment of $26.00. Insurance will not be billed or cover changes for missed or late cancellation fees.

An appointment is considered missed when any of the following occur:

The appointment is cancelled within 24 hours of the scheduled meeting time
The patient does not present to the office for the scheduled appointment
The patient arrives more than 10 minutes late

After the third missed appointment within a one-year time period, we reserve the right to remove you from our schedule at which point your account will be reviewed by your provider

I have read and understand Lifestages Missed Appointment Policy and understand that it is my responsibility to plan and attend appointments I have scheduled. Furthermore, I understand that it is my responsibility to give at least 24-hour advanced notice to Lifestages if I cannot attend my scheduled appointment or I will be charged a fee of $26 for a No Show or Late Cancellation

Signature *

Clear Signature

Date

UPDATED INSURANCE CARD POLICY

Starting January 1, 2025 Lifestages will require that you have a current, active insurance card on file at time of your appointment in order for us to bill your insurance

If you do not have your card at the time of service, you have until the end of the week that you are seen (Friday) to get your insurance information to our office, either in person or by emailing FRONT AND BACK of your insurance card to one of our staff members

Failure to do so, will result in being classified as “Self Pay” for that appointment and ALL charges from your appointment will fall to your responsibility.

Any time there is a change to your insurance you must let us know as soon as possible and get us your new information in a timely manner

***Exception to this rule is newborn babies, we understand that there is delay in insurance information for newborns and will not be available for the first appointment, at least****

I have read and understand Lifestages updated Insurance Card Policy and recognize that is it my responsibility to bring my current insurance information with me to every appointment, or to email to Lifestages as soon as possible, following my appointment in order for my insurance to be billed

Name *

Date of Birth

Signature *

Clear Signature

Today's Date

***If you have not already scheduled an appointment, please call the office at (208) 442-8035 to schedule***

Patient Information

Primary Insurance Coverage

Secondary Insurance Coverage

Pharmacy

Online Portal

Past Medical History (PMH)

Pediatric Demographics

For Newborns

For School-Age Children

Family History

Social History

Review of Systems (ROS)

Regulatory

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

Contact/Records Approval

Office Policies

Missed Appointment Policy

UPDATED INSURANCE CARD POLICY

If you have not already scheduled an appointment, please call the office at (208) 442-8035 to schedule