Forms

PATIENT INFORMATION

Child's Last Name

Child's First Name

Child's Middle Name

Gender
MaleFemale

Date of Birth

Social Security Number

Street Address

City

State

Zip Code

Preferred Pharmacy Name

Cross Street/ Address

Pediatrician / PCP

PCP Phone #

School District

School Name

Race/Ethnicity (Select appropriate group):
AsianBlack/African AmericanLatino/HispanicNative AmericanWhite CaucasianOther

Medication Allergies

Medical History

PARENT/GUARDIAN INFORMATION

Child Lives With
Mother & FatherMotherFatherGurdian/Other

Parent/Guardian’s Last Name

Parent/Guardian’s First Name

Middle Initial

Date of Birth

Primary Phone Number

Alternate Phone Number

Email Address

Opt out of email contact

EMERGENCY CONTACT- In case of an emergency, who should we contact?

Name

Phone Number

Relationship

Children’s Health Pediatric Group may disclose Medical and Billing information to this contact
YesNo

PATIENT/STUDENT ENROLLMENT CONSENT FORM

Child’s Name:

DOB:

HIPAA/FERPA: All students have health issues that must be handled in a confidential manner. Peds Purpose, LLC will share confidential information only in the following situations:
• When the student’s education is affected
• When addressing a student’s healthcare needs
• When safety is an issue
• And other situations specified by law
For example, Peds Purpose, LLC may discuss the student’s medication and other health care needs with the appropriate staff members who will administer the student’s medication and provide care to the student while the student is at school.

I, the undersigned,
• give permission and consent for my child to have treatment through and by Peds Purpose, LLC. I understand the nature of this treatment, the way it is provided, and the details and limitations of Telemedicine.
• give permission for Peds Purpose, LLC to receive information from the school about my child’s healthcare history.
• agree to release all records related to this treatment to the Primary Care Provider
• agree that I will be responsible for all costs associated with said treatment and that I will provide any insurance information as requested. All costs and fees not covered by insurance will be my responsibility.
• agree that the Camden City Board of Education, nor their staff, will be held liable for the services provided by Peds Purpose, LLC
• As Parent/Guardian of the above student, I:
• authorize the release of any information necessary to process insurance claims for payment of benefits Peds Purpose, LLC.
• authorize payment of benefits to Peds Purpose, LLC for services rendered.
• have provided details of all insurance policies that cover my child.
The information above and on the preceding page is true and complete to the best of my knowledge.

Parent/Guardian name PRINTED:

Parent/Guardian SIGNATURE:

Date:

No Telemedicine Services can be provided without a signed consent form.

INSURANCE INFORMATION

Please select the type of insurance for the patient
Commercial InsuranceCHIPMedicaidNone

Name of Person Responsible for Paying the Bill

Primary Phone Number

Relationship to Child
FatherMotherOther

Date of Birth

Address Same as Child?
YesNo

Street Address: Other (City, State, Zip Code)

Policy Holder Relation to Child
Child/PatientMotherFatherGuardian/Other

Name of Insurance Policy Holder

Employer

Insurance Name

Date of Birth

Insurance Phone Number

Insurance ID#

Group#