Monday – Friday: 8:00 AM - 4:30 PM Saturday and Sunday: Closed Closed on Major Holidays
If patient lives at two different addresses, Please provide second address.
I have read and understand the patient policies and agree to abide by its guidelines. I give permission to Pediatrics of Queen Creek to care for and treat my child. I understand my child cannot be treated without my presence unless I have given written consent to an adult OVER THE AGE OF 18 to seek such care or treatment.
Consent to voice messages regarding patient test results (Ex: "We are calling to inform you that your recent lab results came back negative.") No check here means that if you are not available to speak with, you must return the office's call in order to recieve your results.
In my absence the following adults OVER THE AGE OF 18 may seek medical attention for my minor child:
Our practice is committed to providing the best treatment for our patients. Our prices are representative of the usual and customary charges for our area. Thank-you for understanding our patient payment policies. Please inform us if you have any questions or concerns. I HAVE READ AND UNDERSTAND THE PATIENT POLICIES AND AGREE TO ABIDE BY ITS GUIDELINES:
By signing below, I agree I have filled out this form truthfully and to the best of my knowledge.
Please answer all the questions. This will help the doctor decide if your child needs a specific blood test.
1. Does your child live in or regularly visit a house with peeling or chipping paint built before 1960? This could include a day care center, preschool, the house of a baby-sitter or a relative, etc.
2. Does your child live in or regularly visit a house built before 1960 with recent, ongoing, or planned renovation or remodeling?
3. Does your child have a brother or sister, housemate or playmate being treated for lead poisoning?
4. Does your child live with an adult or frequently come in contact with an adult whose job or hobby involves exposure to lead? (Construction, welding, pottery, brass/copper foundry, automotive repair shops.)
5. Does your child eat food, drink juice or punch that has been stored in pottery from mexico or that has been stored in open cans, particulary if the cans are imported?
6. Does your child live near a lead smelter, battery recyling plant, or other industry likely to release lead? (Valve and pipe fittings, pottery, chemical and chemical preparations, industrial machinery and equipment.)
7. Do you give your child any home or folk remedies or traditional medicines that may contain lead?
8. Does your child live near a heavily traveled major highway where soil and dust may contain lead?
9. Does your home's plumbing have lead pipes or copper with lead joints?
10. Do you have any questions about this survey for your doctor?
By signing this form, I authorize PEDIATRICS of QUEEN CREEK to (Check one):
Please note it may take up to two weeks to receive medical records
This authorization applies to the individual described above. Only the checked information will be disclosed in this authorization.
This authorization will expire 1 year from the date it was signed unless otherwise requested.
If requesting records for your personal use, We charge as follows for the preparation and printing of the records:
Up to 50 pages is 50 cents per page.
Anything over 50 pages is $25 plus .25 cents for each additional page.
I understandthe infortmation to be released or disclosed may include information relating to sexually transmitted diseases, AIDS or HIV, and alcohol and drug abuse. I authorize the release or disclosure of this type of information. I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization. The information released in response to authorization may be re-disclosed to other parties. My treatment cannot be conditioned on the signing of this authorization.
This notice describes how health information about you may be used and disclosed and how you can get access to this information. It is effective August 5, 2003, and applies to all protected health information contained in your health records maintained by us. We have the following duties regarding the maintenance, use and disclosure of your health records:
There are a number of situations in which we may use to disclose to other persons or entities your confidential health information. Certain uses and disclosures will require you to sign an acknowledgement that you received this Notice of Privacy Practices. These include treatment, payment, and health care operations. Any use or disclosure of your protected health information required by law, or under emergency circumstances, may be made without your Acknowledgement or Authorization. Under any circumstance, we will use or disclose only the minimum amount of information necessary from your medical records to accomplish the intended purpose of the disclosure.
We will attempt in good faith to obtain your signed Acknowledgement that you received this Notice to use and disclose your confidential medical information for the following purposes. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office once you have provided Consent.
Treatment: We will use your health information to make decisions about the provision, coordination or management of your healthcare, including analyzing or diagnosing your condition and determining the appropriate treatment for that conditions. It may also be necessary to share your health information with another health care provider whom we need to consult with respect to you care. These are only examples of uses and disclosures of medical information for treatment purposes that may or may not be necessary in your case.
Payment: We may need to use or disclose your information in you health record to obtain reimbursement from you, your health insurance carrier, or from another insurer for our services rendered to you. This may include determinations of eligibility or coverage under the appropriate health plan, pre-certification and pre-authorization of services or review of services for the purpose of reimbursement This information may also be used for billing, claims management and collection purposes, and related healthcare data processing through our system.
Operations: Your health records may be used in our business planning and development operations, including improvements in our methods of operation, and general administrative functions. We may also use the information in our overall compliance planning, healthcare review activities, and arranging for legal auditing functions.
There are certain circumstances under which we may use or disclose your health information without first obtaining your Acknowledgement or Authorization. Those circumstances generally involve public health and oversight activities, law-enforcement activities, judicial and administrative proceedings, and in the event of death. Specifically, we may be required to report to certain agencies information concerning certain communicable diseases, sexually transmitted diseases or HIV/AIDS status. We may also be required to report instances of suspected or documented abuse, neglect or domestic violence. We are required to report to appropriate agencies and law-enforcement officials information that you or another person is in immediate threat of danger to health or safety as a result of violent activity. We must also provide health information when ordered by a court of law to do so. We may contact you from time to time to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. You should be aware that we utilize an "open adjusting room" in which several people may be adjusted at the same time and in close proximity. We will try to speak quietly to you in a manner reasonably calculated to avoid disclosing your health information to others; however, complete privacy may not be possible in this setting.
Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, relative, a close friend or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.
We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your healthcare.
Communication Barriers and Emergencies: We may use and disclose your protected health information if we attempt to obtain consent from you but are unable to do so because of substantial communication barriers and we determine, using professional judgment that you intend to consent to use or disclosure under the circumstances. We may use of disclose your protected health information in an emergency treatment situation. If this happens, we will try to obtain your consent as soon as reasonably practicable after the delivery of treatment If we are required by law or as a matter of necessity to treat you, and we have attempted to obtain your consent but have been unable to obtain your consent, we may still use or disclose your protected health information to treat you.
Except as listed above, your health information will not be used or disclosed to any other person or entity without your specific Authorization, which may be revoked at any time. In particular, except to the extent disclosure has been made to governmental entities required by law to maintain the confidentiality of the information, information will not be further disclosed to any other person or entity with respect to information concerning mental-health treatment, drug and alcohol abuse, HIV/AIDS or sexually transmitted diseases that may be contained in your health records. We likewise will not disclose your health-record information to an employee for purposes of making employment decisions, to a liability insurer or attorney as a result of injuries sustained in an automobile accident, or to educational authorities, without your written authorization.
You have certain rights regarding your health record information, as follows:
You may file a written complaint to us or to the Secretary of Health and Human Services if you believe that your privacy rights with respect to confidential information in your health records have been violated. All complaints must be in writing and must be addressed to the Privacy Officer (in the case of complaints to us) or to the person designated by the U.S. Department of Health and Human Services if we cannot resolve your concerns. You will not be retaliated against for filing such a complaint. More information is available about complaints at the government's web site: http://www.hhs.gov/ocr/privacy/hipaa/complaints/
All questions concerning this Notice or requests made pursuant to it should be addressed to:
PRIVACY OFFICER, PEDIATRICS OF QUEEN CREEK 22707 S. ELLSWORTH RD., STE. H101 QUEEN CREEK, AZ 85142
Doctors and hospitals can give you better healthcare by sharing your health information electronically. This is very important in emergencies. This sharing is done electronically through Health Current, Arizona’s health information exchange (HIE).
Many doctors’ offices and hospitals are switching from paper medical records to electronic medical records. During your most recent doctor’s visit, you may have noticed your doctor using a laptop or tablet to type in your health information. Now that your health information is stored safely in a computer, it can be shared more easily among your doctors’ offices, hospitals, labs, and radiology centers. Your health information is shared securely through the HIE.
For details about how your health information will be shared and how it will be protected, please read the Notice of Health Information Practices you received at your doctor’s office.
NOTE: If you do not want your health information shared through HIE, please ask your provider for an Opt Out Form. For more information, visit www.healthcurrent.org and click on the Patient Rights button.
Pediatrics of Queen Creek participates in a non-profit, non-governmental health information exchange (HIE) called Health Current. It will not cost you anything and can help your doctor, healthcare providers, and health plans better coordinate your care by securely sharing your health information.
I acknowledge that I received and read the Notice of Health Information Practices. I understand that my healthcare provider participates in Health Current, Arizona’s health information exchange (HIE). I understand that my health information may be securely shared through the HIE, unless I complete and return an Opt Out Form to my healthcare provider.
Pediatrics of Queen Creek participa en una organizacion sin animo de lucro, organizacion no gubernamental de intercambio de informacion sobre la salud (HIE-por sus siglas en ingles) llamada Health Current. Esto no le generara ningun costo y puede ayudar a su medico, proveedores de salud y planes de salud a coordinar mejor su cuidado compartiendo de forma segura su informacion medica. Este aviso explica como funciona el programa HIE y le ayudara a entender sus derechos con repesto al mismo bajo las leyes estatales y federales.
Yo reconosco que he recibido y leido el Aviso de Practicas de Informacion de la Salud. Yo estoy consiente que mi proveedor participa en el HIE (Arizona’s Health Information Exchange). Yo estoy consiente que mi informacion de la salud sera compartida de manera segura atravez del sistema HIE, al menos de que llene una forma de Optar Por No.
22707 S Ellsworth Rd, Suite H101 Queen Creek, AZ. 85142 (near Ellsworth and Ocotillo Rds)
Fax: (480) 792-9206
Monday – Friday: 8:00 AM - 4:30 PM Saturday and Sunday: Closed
Closed on Major Holidays
Copyright © 2021 Pediatrics of Queen Creek | All Rights Reserved
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