Pediatric Associates of Lawrenceville

PAL’s office is open Monday through Friday, 8am to 5pm, and most Saturday mornings. We see patients by appointment only for health checks, consultations, and sick visits. Saturday appointments are reserved for patients with acute illness. For sick visits, please call as early in the day as possible so that we can evaluate your child.

Please complete and submit the following form before your first visit and one of PAL's office staff will process your online preregistration as soon as possible.

Fields marked with an asterisk (*) are optional. All other fields are required.

Step 1 of 7: Patient Information

Attending doctor
Full name (first, mi, last)
Date of birth
Sex / race
Mailing address
Mailing city / state / zip
Contact telephone number
Alternate telephone number*
Social Security number
Referred by
Brothers and sisters*
Emergency contacts (other than parents)	name: tel:
Emergency contacts (other than parents)	name: tel:

Step 2 of 7: Parent/Guardian Information

Mother's name (first, mi, last)
Date of birth
Mailing address
Mailing city / state / zip
Contact telephone number
Alternate telephone number*
Contact e-mail address
Social Security number

Father's name (first, mi, last)
Date of birth
Mailing address
Mailing city / state / zip
Contact telephone number
Alternate telephone number*
Contact e-mail address
Social Security number

Step 3 of 7: Insurance Company

Primary insurance co.
Secondary insurance co.
Policy holder

I voluntarily consent to examination and treatment for myself and/or my dependents.
REGARDING INSURANCE: With proper insurance identification, this office will bill your Insurance, Managed Care, HMO or PPO provider for our usual and customary charges as a courtesy to you. In the event we do not receive payment in full of our usual and customary charges from your insurance provider within 45 days of billing, the amount owing will be billed to you and payment expected within 30 days after billing to you. All co-pay and deductible portions are due prior to treatment where we are a participating provider for such plan.
PROVIDER CHANGES: It is the responsibility of the parent/guardian(s) to provide this office with any future changes in insurance plans, referrals and pre-certification forms (as required by your individual Insurance Plan) prior to treatment, and to make certain that we are listed as your primary care provider where necessary.
NON-PAYMENT: I understand that if my account is turned over to a collection attorney or a collection agency for non-payment I will be responsible for any additional fees as allowed by law and I will be dismissed from the practice.
I/We authorize release of any medical information and billing information to any third party in order to necessitate payment to this office. I/We authorize and direct any Insurance Provider to pay all benefits payable to me/us directly to this office (a photocopy of this agreement may be used in lieu of original).
I have read and understand these terms

Step 4 of 7: Patient Medical History

Birth history
Birth weight
Birth length
Illness during pregnancy*
Delivery problems*
Do you think your child's development is delayed? If delayed, please explain*	On target Delayed

Has your child even been hospitalized or had surgery? If yes, please explain*	Yes No

Any recurring/major illnesses or injuries? If yes, please explain*	Yes No

Any school problems/issues? If yes, please explain*	Yes No
Any school problems/issues? If yes, please explain*
Other concerns?

Step 5 of 7: Family Medical History

Has anyone in your child's family had any of the
following diseases?
Check all that apply

Alcohol / drug use	Cancer
Asthma / allergies	Diabetes
Behavior problems	Seizures / epilepsy
Birth defects	HIV/AIDS
Blood disorders / sickle cell
Hearing / vision problems

Has anyone in your child's family had any of the following
Check all that apply

High cholesterol	Obesity
High blood pressure	Early heart attack

Step 6 of 7: Office Policy and Procedures

PHONE SYSTEM: When you call our office, the phone system will be answered by our automated telephone system. Please listen carefully to the menu so that your call is directed to the appropriate. department with little or no waiting time.

CELL PHONES: Please turn cellular phones off before entering exam rooms.

WALK-INS: If you walk in without an appointment, you may be directed to the Urgent Care Facility or the Emergency Room. We work by appointment only.

SICK VISITS: If your child is sick, please make an appointment as early in the day as possible. We . work by appointment only; no walk-ins. Patients arriving later than 20 minutes after the scheduled appointment time will have the option to reschedule or wait" for the next available appointment that day. Please be courteous and notify us as soon as possible if you will not be keeping your appointment, so that we may offer the appointment time to another sick child.

HEALTH CHECKS: Try to schedule the health check appointment for your child in advance. This will enable us to accommodate your schedule and allow your child's physician to spend ample time answering your questions and evaluating your child. Patients arriving late (20 minutes after scheduled appointment time) will need to reschedule. We understand that situations arise where you cannot keep an appointment. Kindly notify us 24 hours in advance if you are unable to keep an appointment, or you may incur a missed appointment fee.

SATURDAY HOURS: We provide Saturday morning hours in order to see your SICK child. Please call our office as early as possible to schedule an appointment. Phones are answered beginning at 9am. No walk-ins please.

SIBLING POLICY: If you have another child with you today who is ill and is not originally scheduled to see the doctor, please immediately notify the front desk so that we may try to accommodate your child. DO NOT wait to inform us after you have entered the exam room.

NURSE PHONE CALLS: The nurse line receives a high volume of calls. For your convenience, there is a voice mail system on this line. Please leave your name and phone number and spell your child's name and date of birth. One of our nurses will return yaw. call as soon as possible. Morning calls are returned by 12:30pm, and afternoon calls by 5pm.

PRESCRIPTION REFILLS: For medication that cannot be called in, please notify us 24 hours in advance for picking up a prescription. The nurse will call in other medication refills as quickly as possible.

MEDICAL/IMMUNIZATION RECORDS: Please give a minimum of24 hours notice for completion of school forms. This includes immunization records and physical forms. For a copy of the full chart, a medical record release form must be signed. Once we have the signed release form, there is a minimum of 72 hours before these records become available. If a second release is requested a $15 charge will apply. If you are a new patient or have changed pediatricians or have received immunizations from the Health Department, please check with our staff to make sure we have your child's immunization records on file. In the instance your child's immunization records are not found or are not shown "up-to-date", it is your responsibility to obtain the missing records. We highly recommend that you keep a personal copy of your child's immunization records – we would be happy to make a copy for you!

INSURANCE: To properly me your insurance claim(s), we must obtain a current copy of your child's insurance card each time you visit our office. This will help your insurance pay your claims in a timely manner and save you from being billed. In the event you do not provide proof-of-insurance, payment will be expected at the time of service. Further, if you provide us with incorrect insurance information, you will be responsible for the bill.

It is your responsibility to contact your insurance company and find out whether or not our doctors are participating physicians within your particular insurance plan. Some insurance carriers have a PPO, HMO, POS, or indemnity status, and it is very possible that our doctors may participate in only one of these areas, not in all.
It is also your responsibility to read and understand your own insurance policy. Certain services and procedures may/may not be covered depending on your own insurance policy.
The following circumstances may result in you being billed directly:
- we are not participating physicians in your plan; insurance coverage is not in effect because of the date of visit
- non-covered lab work is ordered/performed
- or a non-covered service is performed,or denied for the reason "not medically necessary"
Co-payment is due at the time of service by the person bringing the patient for the visit. If you do . not have your oo.pay we will bill you for a $15 adminiStrative fee. If someone other than the parent or guardian is' bringing the patient, a notice stating approval of the visit must be signed by the parent/guardian and presented at check-in.

REFERRALS: Referrals may be needed for specialists, emergency room visits, urgent care visits, etc. It is your responsibility to determine if Your insurance requires a referral for health care visits outside of our office. If you do need a referral, please contact our office with an appointment date and time. We need 3 working days to obtain a referral from your insurance.

LABS X-RAYS, OR OTHER AMBULATORY CARE SERVICES: If labs, x-rays, or other ambulatory care services are required beyond your office visit, it is your responsibility to know where your insurance company covers you to go for these services. Each insurance company; contracts with different companies.

I have read and understand these terms

Step 7 of 7: Patient Authorization for Use and Disclosure of Protected Health Information for Purposes Requested by PAL

By signing this authorization, I authorize Pediatric Associates of Lawrenceville, LLC (pAL) to use/or disclose certain protected health information (PHI) about:
Child's full name

This authorization permits PAL to use and/or disclose the following individually identifiable health information (specifically describe the information to be used or disclosed, such as date(s) of services, type of services, level of detail to be released, origin of information, etc.):
The information will be used or disclosed for the following purposes: Insurance information, further medical care, immunization forms to schools, daycare, college forms, camp forms ,sports physical forms, and to call prescriptions to pharmacy.
Other purposes*

The purpose(s) is/are provided so that I can make an informed decision whether to allow release of the information. This authorization will expire on
Expiration date	Child's 21st Birthday

The Practice will not receive payment or other remuneration from a third party in exchange for using or disclosing the PHI.
I do not have to sign this authorization in order to receive treatment from PAL. In fact, I have the right to refuse to sign this authorization. I also have the right to inspect or copy the information to be used or disclosed. When the information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIP AA Privacy rule. I have the right to revoke this authorization in writing except to the extent that the Practice has acted in reliance upon this authorization. My written revocation must be submitted to the Privacy Officer at:
755 Old Norcross Road Lawrenceville, Georgia 30045
I acknowledge receipt of the Notice of Privacy Practices of Pediatric Associates of Lawrenceville, LLC.

Parent or legal guardian
Patient's name

Insurance Policy
If you are a member of one of the many managed health care plans, please ensure that your PAL doctor is a member of your particular plan prior to your appointment, so that out-of-network charges are not incurred, by calling the member services number on your insurance card.

If insurance does not pay your claim in 90 days, you will be responsible for the balance.

Please allow our staff 1 to 3 business days to process your online preregistration. If you experience difficulty completing this form, or would rather contact PAL by telephone, please call 770.277.6725.
contact PAL