Northern Virginia Pediatric Associates, P.C. 107 North Virginia Ave, Falls Church, VA 22046 24 Hour Phone #: (703) 532-4446 | Fax #: (703) 532-8426 By Appointment Only Monday - Friday: 8:00 am - 7:00 pm Saturday: 8:00 am - 1:00 pm Sunday & Holidays: 9:00 am - 12 pm Copyright © 2017 Northern Virginia Pediatric Associates, P.C. All Rights Reserved. Thank you for using our online forms. Please note that the collected data from online submitted forms will be deleted within 48 business hours by one of our team members for security purposes.
CHILD - PATIENT INFORMATION Chart # (Last three digits of mom’s SSN #)
Please select primary provider
Phone # (1)
Phone # (2)
Health Insurance Name
Name of Policy Holder
Date of birth of policy holder
Billing Address if Different From Home Address
If Divorced, Name of Parent Child Resides With
Phone # (Health Insurance)
I hereby give my permission to any of the Practice Doctors or their designated alternates, to take necessary medical action in emergency situation for my child/children when I am not immediately available.
Please enter your initials #1
Our practice follows guidelines for immunization and routine lab tests set by the American Academy of Pediatrics. You may be responsible for partial or total payment of some of these procedures depending on your insurance coverage. Patients are responsible for knowing what their insurance company covers prior to their visit. The patient should settle any problems with coverage or reimbursement directly with the insurance company.
Please enter your initials #2
I acknowledge that it is the policy of this office that payment is requested at each visit and I am responsible for payment of all services rendered. If the treating physician is a participant in a managed care plan of which I am a member, I agree to pay any co-payment required by my particular plan at the time of visit.
Please enter your initials #3
I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information, for this or any related claim to determine the insurance benefits to which I may be entitled.
Please enter your initials #4
Signature (Please sign, date and initial at time of first visit)
As part of my child’s health care, Northern Virginia Pediatric Associates, P.C. (the practice) has given me the option to have my child’s personal health information left in message form on my personal telephone answering device. This would include lab studies, consultative reports and changes in medication, and other pertinent health information.
Patient Consent - Yes or No
If yes, please enter phone #
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 that treatment directly and indirectly.- Obtain payment from third-party payers.- Conduct normal healthcare operations such as quality assessments and physician certifications.I have been informed of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization 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 below to obtain a current copy of the Notice of Privacy Practices.I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand 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.
Child's Name (Consent)
Parent’s or Legal Guardian’s Name
Parent’s or Legal Guardian’s signature
List Current Medical Issues
List current medications, dose and frequency
List names of specialists who regularly see child
Ear, Nose & Throat
Urinary tract & Bladder
Arms & Legs
If yes, please explain (150 chars left)
If yes, type of allergy & medicines used (150 chars left)
If present report medicines used on daily basis and as needed (150 chars left)
Do you have concerns about your child’s development or learning abilities? (150 chars left)