Child Patient Registration - Medical Associates of Northwest Arkansas

Patient Registration Form for Child, MANA Family Medicine Prairie Grove

Patient's Legal Name*
First Middle Last
Preferred Name*
Today's Date*

Date of Birth*

Social Security Number
Please enter number without hyphens.
Sex
Male
Female
Prefer Not to Answer
Please check one:
White
African American
Asian
Native Hawaiian/ Other Pacific Islander
Native American/ Alaskan
Are you of Spanish/ Hispanic heritage?
Yes
No
Preferred Primary Language
Primary Physician
Preferred Pharmacy
Please include street and city so we know which branch you prefer.
Would you like to have access to your health record and communicate online with your physician office through a secure myMANA Health Portal?
Yes
No
Person Responsible for Payment
Guardians and foster parents, please complete the parent information and indicate that the child is in your custody.
Name of Responsible Party*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone*
Mobile Phone
Father's Name
First Last
Father's Date of Birth

Father's Social Security Number
Please enter numbers without hyphens.
Employer
Cell Phone
Work Phone
Mother's Name
First Last
Mother's Date of Birth

Mother's Social Security Number
Please enter number without hyphens.
Employer
Cell Phone
Work Phone
Please check one:*
Married
Single
Partner
Divorced
Widowed
Preferred Communication Method
Text
Phone
Emergency Contact Information
Emergency Contact*
Relationship*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient Notice of Privacy Practices Acknowlegement
If you would like to authorize MANA clinic to release information to a family member, spouse, or personal representative, please complete the Individual Authorization Form at the bottom of this document.
I have received a copy of the Patient Notice of Privacy Practices from Medical Associates of Northwest Arkansas.
Signature*
Choosing "Yes" below is my electronic signature.
Yes
No
Today's Date*

Representative
In the event this Acknowledgement form is being executed by a personal representative, guardian or parent, please give your name, date of birth, social security number and relationship to the patient here:
How did you hear about us?
Thank you for choosing a MANA clinic. How did you hear about us? Check all that apply.
Use the shift key to choose more than one option.
Health Insurance Information
Please provide a copy of your insurance card to the receptionist. Fill out Medicare information if you use Medicare.
ARKids First or Medicaid Number
Effective Date

Primary Insurance
Company Name
Insurance ID Number
Group Number
Phone
Policy Holder's Name
Date of Birth

Social Security Number
Relationship of Patient to Policy Holder
Seconday Insurance Company
Company Name
ID Number
Group Number
Phone
Policy Holder's Name
Date of Birth

Social Security Number
Relationship of Policy Holder to Patient
Patient Authorization*
PATIENT AUTHORIZATION I hereby authorize Medical Associates of Northwest Arkansas {MANA), in its sole discretion, to seek payment of charges for all services rendered during or in connection with my medical treatment from my insurer and/or from third parties {or their insurers} who may have caused, or otherwise be liable for, the incident, injury or condition giving rise to my need for medical treatment. I understand that in the event MANA attempts to collect from those third parties, such attempts are in lieu of, or in addition to, MANA seeking payment from my current medical insurance provider. I understand and agree that any discounts which MANA has agreed to accept from my medical insurance provider will not be applied to reduce amounts payable by, or recoverable from, third parties or their insurers. I hereby assign and authorize payment directly to MANA of all insurance benefits, sick benefits and injury benefits due because of liability of a third party and proceeds of all claims resulting from the liability of a third party to me or for my benefit unless all charges are paid in full immediately upon completion of my medical treatment. I further agree that this assignment will not be withdrawn at any time until the account is paid in full and consent to MANA's assertion of subrogation or lien rights, if necessary, to protect MANA's interest in recovering from third parties the full amount of charges for services rendered during or in connection with my medical treatment. I agree to pay at the time of service any co-pay or amount otherwise required by my current medical insurance provider and understand that I am responsible for any amount not covered by Insurance or collected by MANA from a third party. MANA Is authorized to give information regarding me, my case and my medical treatment to my current medical Insurance provider and/or to potentially financially responsible third parties and their insurers. By choosing YES below I sign this statement.
Yes
No
Child Health History
Your child's overall health as well as any medications your child takes could have an important interrelationship with the care your child receives. Please answer each of the following questions completely.
Name
First Last
Today's Date

Date of Birth

Mother's Maiden Name
First Last
Social Information
Please check any problems your child currently has or has ever had. Use the shift key to choose more than one option.
Number of meals a day
Number of snacks a day
Does your child get along well with other children?
Yes
No
Is your child doing well in school?
Yes
No
If child is of school age
Is your water fluoridated?
Yes
No
Pregnancy/Birth History
Child's birth weight
Delivery
Vaginal
C-section (elective or emergency)
Was your child born more than two weeks early or late?
Was your child breastfed?
Yes
No
Age breastfeeding was discontinued
Did the mother use cigarettes, alcohol, drugs, or medications during pregnancy?
Yes
No
Past Medical/Surgical History
Please mark any problems your child has ever had.
Use the shift key to choose more than one option.
Please explain any medical problems your child has had.
Please list any hospitalizations, serious or unusual illnesses which your child has experienced.
Date Hospitalization or illness Hospital/Physician City/State

Use the + button to make more rows if needed.
Please list all medications your child currently takes.
Date Medications/Strength Frequency Condition

Use the + button to make more rows if needed.
Allergies
Please list all allergies, sensitivities, and/or reactions to any drugs.
Child's Father
Age
State of Health
Age at Death
Health Conditions
Child's Mother
Date of Birth

State of Health
Age of Death
Health Conditions
Other Family Members
Child's Siblings
Please list age, state of health, age at death, and health conditions for any siblings. Use the + button to add more rows.
Sibling 1 Sibling 2 Sibling 3

Mark any diseases known to have occurred in the family with the appropriate initial: M(Mother), F(Father), GM (Grandmother), GF(Grandfather), A(Aunt), U(Uncle), C(Cousin), B(Brother), S(Sister). Use the + button to add more rows if needed.
Alzheimer Asthma Alcoholism Blood Disease Coronary Artery Disease Cancer Stroke Depression Development Problems Diabetes

Hearing Problems Cholesterol High Blood Pressure Mental Disease Migraines Obesity Blood Clots Kidney Problems Seizures Sickle Cell

Pharmacy Information
Please list your preferred pharmacy, with street and city.
My choice of YES below serves as my electronic signature.*
To the best of my knowledge, the questions on this form have been accurately answered.I understand the providing incorrect information can be dangerous to my child's health. It is my responsibility to inform the doctor's office of any changes in my child's medical status. I also authorize the healthcare staff to perform the necessary services my child needs.
Yes
No
Authorization to Individuals
I give all physicians and professional staff employed by Medical Associates of NWA, PA, permission to disclose the protected health information set forth below to the following people at the request of one or more of these individuals.
Patient Name
First Last
Date of Birth

Information to be released to the below referenced entity:
Specific Information
Use + button to add more rows
Name Relationship to patient Phone

I give Medical Associates of Northwest Arkansas P.A., permission to fax my child’s School Excuse to his/her school.
Yes
No
I give Medical Associates of Northwest Arkansas P.A., permission to leave a message (s) on my answering machine if they should need to remind me of an appointment, change an appointment, etc, and are unable to reach me in any other way.
Yes
No
Electronic Signature
In addition, I understand or acknowledge the following: 1. I understand that Medical Associates of Northwest Arkansas, P.A ., will not release any information to any person(s) not listed above. 2. I have the right to revoke this Authorization at any time by giving Medical Associates of Northwest Arkansas, P.A., a written notice. I understand this does not apply to the release of PHI pursuant to my prior authorization. 3. I have received Medical Associates of Northwest Arkansas’s Notice of Privacy Practices 4. My protected health information may be subject to re-disclosure by one or more of the persons named above and as such may no longer be protected by federal or state law. 5. My treatment is not conditional on signing this statement, except as allowed by Privacy Rule.
Yes
No
In the event the Authorization is being executed by a personal representative, guardian, or parent, please print your name, relationship to the patient, and basis of authorization to act on the patient’s behalf.
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Mumps/Measles
Chicken Pox
High cholesterol
Pneumonia
Asthma/Wheezing
Cancer
Hepatitis
HIV/AIDS
Hemophilia
Abnormal bleeding
Allergies
Frequent ear infections
Frequent colds
Croup
TB/Lung disease
Kidney/Bladder infections
Emotional disorder
Sexually transmitted diseases
Eczema/Skin problems
Handicaps/ Disabilities
Diabetes
Rheumatic fever
Congenital heart defect
Heart murmur
Convulsions/Epilepsy
Suicide attempts