Patient Registration

About Us

We give personal care to patients. We work with specialists, the emergency room and other providers. We will help you understand labs, X-ray, and diagnostic testing results. We help you take care of your child after a hospital stay.

Contact Info

777 Franklin Gateway SE, Marietta, GA 30067

++770-732-6007

info@internationalclinics.org

PATIENT INFORMATION

Last name*

First Name*

Date of Birth*

Sex*
MaleFemale

Home Address*

City*

State*

Zip Code*

Daytime Phone

Cell Phone*

Please list any allergy information

PRIMARY CARE PHYSICIAN INFORMATION

Physician Name*

Fax

Phone

PHARMACY INFORMATION

Pharmacy Name*:

Phone*

Fax:

GUARDIAN INFORMATION (Parents or Legal Guardian)

(Tenga en cuenta que la persona que tenga la custodia legal del paciente; si no son los padres, deberá presentar los documentos necesarios al momento de la cita.)

Name*:

Last Name*:

Date of Birth*:

Social Security #:

Email*:

Home Address

City

State

Zip Code

EMERGENCY CONTACT INFORMATION

Full Name*:

Phone*:

Relationship*:

PARTY RESPONSIBLE FOR PAYMENT

(If different from patient)

Relationship to patient*:

First Name*:

Last Name*:

Date of Birth*:

Social Security #*:

Home Address*:

City*:

State*:

Zip Code*:

Cell Phone:

Business Phone:

INSURANCE INFORMATION

Name of Insurance Company*:

Address:

City:

State:

Zip Code:

Phone:

I authorize any treatment or medical procedure necessary for the medical care of my child that is required by International Pediatric Clinics.

Name of patient*:

Signature of legal custodian*:

Date*:

International Pediatric Clinics
Financial Policy

Insurance

We participate with most insurance plans. If you are not insured, payment for services is required in full at each visit. We will submit your claim(s) to your insurance company and assist you in any way we can to expedite the processing of your claim. Please be aware that at times your insurance company may request certain information directly from you in order to process your claim. It is your responsibility to comply with their request. Please notify our office immediately should you have any changes to your insurance information. You may be responsible for the claim(s) should you fail to provide the current insurance information in a timely manner. If your insurance company does not process your claim in 60 days, the balance of the claim(s) will automatically be billed to you.

Please initial that I have read and agreed to the above statement*.

Co-payments and Deductibles

All co-payments and deductibles must be paid at the time of service as part of your contract with your insurance company. Payment in full is required at the time of service for any past due balance on your account. Any check returned for insufficient funds will be subject to a $25.00 service charge. Please be aware that if an unpaid balance remains on your account and is over 90 days past due, we may refer your account to a collection agency.

Please initial that I have read and agreed to the above statement*.

Appointment Cancellations

Our policy is to charge for missed appointments as this may prevent another patient from their treatment. However, we understand that there are times when you must miss an appointment due to prior obligations or an unseen emergency. We ask that you notify our office within 24 hours of your scheduled appointment so that we may assist you. If you are unable to reach our office during business hours, please leave a message on our voice mail. .

Please initial that I have read and agreed to the above statement*.

We realize that temporary financial situations may affect timely payment on your account. We encourage you to contact our billing department within our office and we will gladly work out payment arrangements on your account. .

Our practice is committed to providing the best treatment to our patients. Please let us know if you have any questions or concerns.

I authorize International Pediatric Clinics to release any medical or other information to the insurance carrier, which may be necessary to process the claims. I authorize my insurance company to pay for services provided. I have read and understand the financial policy and its guidelines.

Name of Legal Custodian (Written)*:

Name of patient*:

Signature of legal custodian*:

Date*:

PATIENT AUTHORIZATION TO USE AND DISCLOSE
MEDICAL INFORMATION CONFIDENCEL

i, authorize the adults I name below to take my child and discuss the necessary information with the International Pediatric Clinics, for the well-being of the patient.

Name*:

Relationship with the Patient*:

Phone*:

Name:

Relationship with the Patient:

Phone:

Name:

Relationship with the Patient:

Phone:

With my consent, International Pediatric Clinics may use and disclose protected Health Information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to International Pediatric Clinics Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. International Pediatric Clinics reserves the right to revise its Notice of Privacy Practices at any time.

A revised Notice of Privacy Practices may be obtain by forwarding a written request to, International Pediatric Clinics Attn: Privacy Officer at 780 Canton Rd., Suite 350, Marietta, Georgia 30060.

With my consent, International Pediatric Clinics may call my home or other designated location and leave a message on voice mail or in person in reference to any items and any call pertaining to my clinical care, including laboratory results among others.

With my consent, International Pediatric Clinics may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment cards and patient statements.

With my consent, International Pediatric Clinics may e-mail my appointment reminder cards and patient statements. I have the right to request that International Pediatric Clinics restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bounded by this agreement.

I may revoke my consent in writing except that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent International Pediatric Clinics may decline to provide treatment to me.

Signature of Father / mother or legal guardian:

Date:

Written name of Father / mother or legal guardian:

Name of patient:

About Us

Contact Info

PATIENT INFORMATION

PRIMARY CARE PHYSICIAN INFORMATION

PHARMACY INFORMATION

GUARDIAN INFORMATION (Parents or Legal Guardian)

(Tenga en cuenta que la persona que tenga la custodia legal del paciente; si no son los padres, deberá presentar los documentos necesarios al momento de la cita.)

EMERGENCY CONTACT INFORMATION

PARTY RESPONSIBLE FOR PAYMENT

(If different from patient)

INSURANCE INFORMATION

I authorize any treatment or medical procedure necessary for the medical care of my child that is required by International Pediatric Clinics.

International Pediatric Clinics
Financial Policy

Insurance

Co-payments and Deductibles

Appointment Cancellations

PATIENT AUTHORIZATION TO USE AND DISCLOSE
MEDICAL INFORMATION CONFIDENCEL

Contact & Support

Telephone

Email

Opening Hours

About Us

Contact Info

PATIENT INFORMATION

PRIMARY CARE PHYSICIAN INFORMATION

PHARMACY INFORMATION

GUARDIAN INFORMATION (Parents or Legal Guardian)

(Tenga en cuenta que la persona que tenga la custodia legal del paciente; si no son los padres, deberá presentar los documentos necesarios al momento de la cita.)

EMERGENCY CONTACT INFORMATION

PARTY RESPONSIBLE FOR PAYMENT

(If different from patient)

INSURANCE INFORMATION

I authorize any treatment or medical procedure necessary for the medical care of my child that is required by International Pediatric Clinics.

International Pediatric Clinics Financial Policy

Insurance

Co-payments and Deductibles

Appointment Cancellations

PATIENT AUTHORIZATION TO USE AND DISCLOSE MEDICAL INFORMATION CONFIDENCEL

Contact & Support

Telephone

Email

Opening Hours

International Pediatric Clinics
Financial Policy

PATIENT AUTHORIZATION TO USE AND DISCLOSE
MEDICAL INFORMATION CONFIDENCEL