We have moved to a new location - 7200 State Hwy 161 #100, Irving, TX 75039

Our new location - 7200 State Hwy 161 #100, Irving, TX 75039

New Patient Registration Form

Personal Details / Detalles personales
Parent or Guardian Information / Información de los padres o tutores
Emergency Contact / Contacto de emergencia
Insurance Information / Información del seguro
HIPAA Release Form

First Name / Primer Nombre*

Middle Name / Segundo Nombre

Last Name / Apellido*

Patient's Sex / Sexo del paciente*

Male / Masculino

Female / Femenina

Others / Otros

Patient's Date of Birth / Fecha de nacimiento del paciente*

Address Line 1 / Dirección Línea 1*

Address Line 2 / Dirección Línea 2

City / Ciudad*

State or Province or Region / Estado o Provincia o Región*

Zip or Postal Code / CP o Código Postal*

Country / País*

United States

Canada

Email*

Patient's Social Security Number / Número de seguro social del paciente

Best Contact Number / Mejor número de contacto*

Best Contact Number Type / Mejor tipo de número de contacto*

Cell / Teléfono móvil

Home / Hogar

Work / Trabajar

Pharmacy Name / Nombre de la farmacia

HIPAA Disclosure*

I understand that, under the health insurance portability and accountability act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. protected health information (phi) may originate in your medical record at pediatric health specialists, or may be received from outside health entities and filed in your medical record. I understand that this information can and will be used by pediatric health specialists to: a) conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly or indirectly b) obtain payment from third-party payers c) conduct normal healthcare operations such as quality through pediatric health specialists or networking organizations, and d) consent to property transfer of specimen (tissue obtained during medical testing) to pediatric health specialists. I have been informed by you of your notice of privacy practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its notice of privacy practices from time to time and that I may obtain a current copy of the notice of privacy practices from my office or by contacting pediatric health specialists, medical city las Colinas, medical plaza, suite 303, 6750 north MacArthur Blvd, Irving, TX 75039. I understand that I may request in writing that you restrict how my private information is used or disclosed for treatment, payment, or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent

First Name of the Patient / Nombre de la paciente*

Middle Name of the Patient / Segundo nombre de la paciente

Last Name of the Patient / Apellido de la paciente*

Date of Birth of Patient / Fecha de nacimiento de la paciente*

Email Consent / Consentimiento de correo electrónico*

By providing an Email address I give Pediatric Health Specialists CONSENT to Email those addresses / Al proporcionar una dirección de correo electrónico, doy mi CONSENTIMIENTO a los especialistas en salud pediátrica para enviar correos electrónicos a esas direcciones

Text Consent / Consentimiento de texto*

By providing a cell phone number I give Pediatric Health Specialists CONSENT to text those numbers / Al proporcionar un número de teléfono celular, doy mi CONSENTIMIENTO a los especialistas en salud pediátrica para enviar mensajes de texto a esos números

Signature of Guardian / Firma del Tutor*

Date of Form Submission / Fecha de envío del formulario*

The Texas Immunization Registry Consent for Registration of Child and Release of Immunization Records to Authorized Entities*

The Texas Department of State Health Services encourages your voluntary participation in the Texas immunization registry. ImmTrac2, the Texas immunization registry, is a free service of the Texas Department of State Health Services (DSHS). The immunization registry is a secure and confidential service that consolidates and stores your child’s (younger than 18 years of age) immunization records. With your consent, your child’s immunization information will be included in ImmTrac2. Doctors, public health departments, schools, and other authorized professionals can access your child’s immunization history to ensure that important vaccines are not missed. I understand that, by granting the consent below, I am authorizing the release of the child’s immunization information to DSHS and I further understand that DSHS will include this information in the state’s central immunization registry (“ImmTrac2”). Once in ImmTrac2, the child’s immunization information may by law be accessed by: · a public health district or local health department, for public health purposes within their areas of jurisdiction; · a physician, or another health-care provider legally authorized to administer vaccines, for treating the child as a patient; · a state agency having legal custody of the child: a Texas school or child-care facility in which the child is enrolled; a payor, currently authorized by the Texas Department of Insurance to operate in Texas, regarding coverage for the child. I understand that I may withdraw this consent to include information on my child in the ImmTrac2 Registry and my consent to release information from the Registry at any time by written communication to the Texas Department of State Health Services, ImmTrac Group – MC 1946, P. O. Box 149347, Austin, Texas 78714-9347. Privacy Notification: With few exceptions, you have the right to request and be informed about the information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect By my signature below, I GRANT consent for registration. I wish to INCLUDE my child’s information in the Texas immunization registry

Signature of the Guardian / Firma del Guardián*

Date of submission of this form / Fecha de envío de este formulario*

Release of Information / Liberación de información

Please choose one option / Por favor elige una opción*

Pediatric Health Specialists may NOT discuss patient's healthcare and may NOT discuss and/or make financial arrangements with anyone / Los especialistas en salud pediátrica NO pueden discutir la atención médica del paciente y NO pueden discutir ni hacer arreglos financieros con nadie

Pediatric Health Specialists MAY discuss patient's healthcare and MAY discuss and/or make financial arrangements with only the following individuals listed below / Los especialistas en salud pediátrica PUEDEN discutir la atención médica del paciente y PUEDEN discutir y/o hacer arreglos financieros solo con las siguientes personas que se enumeran a continuación

Delegation Of Consent / Delegación de Consentimiento

We understand that on occasion, the need may arise for someone other than the parent/legal guardian Indicated on file to bring in the child for medical care. Below, please indicate those to whom authorization may be given when you are unavailable / Entendemos que, en ocasiones, puede surgir la necesidad de que alguien que no sea el padre/tutor legal indicado en el archivo traiga al niño para recibir atención médica. A continuación, indique a quién se puede otorgar autorización cuando usted no esté disponible

Name / Nombre

Relation to the patient / Relación con la paciente

I authorize the above individual to consent to any and all medical care treatment for this child by a Pediatric Health specialist healthcare provider. This delegation is valid until I have withdrawn this consent / Autorizo a la persona antes mencionada a dar su consentimiento para cualquier tratamiento de atención médica para este niño por parte de un proveedor de atención médica especialista en salud pediátrica. Esta delegación es válida hasta que haya retirado este consentimiento

Patient's Name / Nombre del paciente*

Signature / Firma*

New Patient Registration Form

Primary Claim Mailing Address / Dirección postal de reclamo principal

Release of Information / Liberación de información

Delegation Of Consent / Delegación de Consentimiento

Accessibility Menu

Monday	:	7:30 AM to 4:30 PM
Tuesday	:	7:30 AM to 4:30 PM
Wednesday	:	7:30 AM to 4:30 PM
Thursday	:	7:30 AM to 4:30 PM
Friday	:	7:30 AM to 4:30 PM
Saturday	:	[Closed]
Sunday	:	[Closed]