Online Demographic Form- Must be submitted 3 business days prior to appointment.

PRIVACY ACKNOWLEDGEMENT: I understand the New River Valley Pediatrics’ Notice of Privacy Practice provides me with detailed information on how my child’s protected health information may be used and disclosed. I acknowledge that New River Valley Pediatrics’ Notice of Privacy Practice will be made available to me upon request.

DEEMED CONSENT: I understand that if my child’s physician, or any person employed by or under the direction and control of my child’s physician(s), is directly exposed to my child’s body fluids in any manner which may, according to the the guidelines for the Center for Disease Control, transmit the human immunodeficiency virus (HIV) or Hepatitis B or C virus, that I am deemed by law to have consented to testing for infection with HIV or Hepatitis B or C viruses. I further understand that, by law, I will have deemed to have consented to the release of these test results to the person who is exposed to my child’s body fluids.

MEDICATION CONSENT: I voluntarily consent to any and all health care treatment and CLIA waived procedures provided by New River Valley Pediatrics and its associated physicians and other personnel. I authorize the facility to contact healthcare providers from whom I have received treatment to obtain medical information and/or records including, but not limited to, commercial pharmacies for verification of medications.

ASSIGNMENT OF BENEFITS/PROMISE OF PAYMENT: Authorization is hereby given to release to my insurance company(s) such information that may be necessary for the completion of my child’s clinical insurance claims. I understand I am financially responsible for charges not covered by insurance (co-pays, co-insurance, deductibles, non-covered services) and assign any insurance benefits to New River Valley Pediatrics. Co-pays are due at the time of service. Any co-pays not paid at the time of service are subject to a $10.00 late fee.

CONSUMER CONTRACT: You agree, in order for us to service your account or to collect any amounts you may owe us, we may contact you by telephone at any telephone number associated with your child’s account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or e-mails, using any e-mail addresses you provide to use. Methods of contact may include using pre-recorded/artificial voice messages and/or use of any automatic dialing device, as applicable. I have read this disclosure and agree that your collection agency of choice may contact me as described above. If an account is forwarded to our outside collection agency it is subject to additional fees up to 25% of the amount sent to collections. This is to cover the fee charged by the collection agency and costs to our practice for maintaining accounts in collections.

New River Valley Pediatrics treats all patients and families ethically with respectful, compassionate care. I understand that, if at any time, my behavior or language is inappropriate or disrespectful to any staff or other individuals, I will be subject to immediate dismissal from the practice.

By checking the box below, I am agreeing and acknowledging to the above.

 
* is a required field


SECTION 1: PATIENT INFORMATION

Sex:

Race:





Ethnicity (check one):



 
SECTION 2: APPOINTMENT CONFIRMATION

SECTION 3: MESSAGES
May we leave messages concerning labs, x-rays & appointments, etc?:


SECTION 4: PARENTAL / GUARDIAN INFORMATION

Biological Mother
Is the above the guardian of this child?*:


Biological Father
 
Is the above the guardian of this child?*:


SECTION 5: GUARDIAN CONTACT INFORMATION
If you answered NO to: Are you the guardian of this child in Section 4, please complete this section If you answered YES to: Are you the guardian of this child in Section 4, please skip to Section 6


Guardian 1
Does this patient live with you?:

Guardian 2
Does this patient live with you?:


 
SECTION 6: MEMBERS LIVING IN HOUSEHOLD YOUNGER THAN 18
 

SECTION 7: MEMBERS LIVING IN HOUSEHOLD OLDER THAN 18
 

SECTION 8: EMERGENCY CONTACTS (OTHER THAN PARENTS)
 
The above may*:



The above may*:



SECTION 9: INSURANCE INFORMATION
 
SECTION 10: BILLING INFORMATION
 
Is this person financially responsible for any other children in our practice:

SECTION 11: GUARDIAN SIGNATURE
 

Radford Office

202 8th Street
Radford, VA 24141

Office: 540-639-5188
After Hours: 540-639-5188

Blacksburg Office

805 Davis Street
Blacksburg, VA 24060

Office: 540-552-7272
After Hours: 540-552-7272

Carilion NRV Med Center

2900 Lamb Circle , Suite 160
Christiansburg, VA 24073

Office: 540-639-5620
After Hours: 540-639-5188

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