Agreement * Consent * I agree to use electronic records and signatures.
In order to ensure that Browning Medical Group receives fair compensation for medical care given to my child and the community, I agree to the following:
My insurance is billed out of courtesy. I am responsible for all bills and charges associated with my child’s visit to Browning Medical Group. If my insurance does not pay Browning Medical Group for the visit in a timely manner (within 60 calendar days from when the charges were submitted) I will be responsible to make sure the charges are paid. If I do not pay any outstanding charges within 30 days (90 calendar days from when charges were submitted), or set up a payment plan, I can be sent to collections.
If my account has been sent to collections and then my insurance pays for those charges, Browning Medical Group can refuse payment from my insurance company. Once my account has gone to collections, I understand that I, and my insurance company, will have to deal with the collections company.
Browning Medical Group has an agreement with my insurance in terms of discounts for procedures and visits. If my outstanding balance goes to collections, the charges will revert back to their original amount, and the discount given to the insurance company will be revoked.
If I have a family balance of more than $250, and a payment plan is not set up, I will have to pay 50% of my outstanding balance and set up a payment plan before my child can receive services from Browning Medical Group.
Copays are due at the time of the visit. OPTION 1: Pay balance in FULL. OPTION 2: Pay 50% of balance. OPTION 3: Three biweekly payments.
Any discount given to me for a payment or a payment plan is dependent on me meeting my payment plan obligations, should I violate that agreement, the discounts are null and void.
In order for Browning Medical Group to recoup costs associated with collections, I agree that if my account goes to collections, Browning Medical Group may charge me a service fee equal to 50% of the original balance that will be added to the original balance.
If I miss an appointment without notifying Browning Medical Group 24 hours in advance, I will be charged a $50 no-show fee and agree to pay it within 30 days of receiving the bill for it. If I cancel appointments for any family member within 24 hours, I will be charged a $50 no-show fee. If I cancel more than 3 times, or if I no-show more than 3 times, Browning Medical Group has the right to dismiss me from the practice. If I am more than 5 minutes late to an appointment, Browning Medical Group may require my appointment be rescheduled.
If I don’t have my insurance card at the time of service, Browning Medical Group has the right to refuse service and I may need to go to the ER if it is an urgent care matter.
I acknowledge that I have read the above Payment Policy Agreement. * Parent/Guardian's Name *
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DISCLOSURE OF PROTECTED HEALTH INFORMATION
By acknowledging consent below, I authorize Browning Medical Group and its employees, including Dr Jonathan Slothower, Chad Francom, and Staffing Office to use and disclose certain protected health information (PHI) about my child, or the minor for whom I am the legal guardian (also known here after as “my child”).
This authorization permits Browning Medical Group to access and/or disclose the individually identifiable heath information about my child during the course of medical care, as well as any information collected following medical care or consultation given to my child in a hospital, emergency room, newborn nursery, or via telephone interaction with any employees of Browning Medical Group.
Disclosure of such information will be for the purpose of referral to a subspecialist or another general practitioner, after discussing and documenting the need for such a referral. The information may also be shared with a medical provider who, at the time the information is requested, is actively participating in the medical care of the child represented by this form. The purpose(s) will be provided so that I can make an informed decision whether to allow release of the information.
Browning Medical Group will not receive payment from a third party in exchange for disclosing the PHI, except in the case where such information is requested by the insurance company or third party payer that is financially responsible for part or all of the medical expenses that my child has accrued while being associated with Browning Medical Group.
Browning Medical Group may at times use secure, healthcare-approved, HIPAA compliant Artificial Intelligence (AI) tools to assist with patient care. These tools may be used for assisting in creating medical notes and documentation, improving office efficiency and reducing wait times, and enhancing communication between healthcare providers.
By signing, I authorize Browning Medical Group to access my child’s previous prescription medication history. With this consent, Browning Medical Group may telephone/e-mail my home, or other locations that I designate, any items that may assist the practice in carrying out treatment plan options, such as appointment reminder cards and patients statements.
I do not have to sign this authorization in order to receive treatment from Browning Medical Group. I have the right to refuse to sign this authorization. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization.
I acknowledge that I have read the ABOVE Disclosure of Protected Heath Information. * Parent/Guardian's Name *
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Patient Name *
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Patient Gender * Patient's Place of Birth * Patient's Address * Check this box if there is only 1 parent for this patient. Parent #1 Name *
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Parent #2 Name *
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Race * Ethnicity * Primary Language * Referred by: The Following Information Helps Us Send Out Announcements if We are Closed via Text , Email and Phone calls. Please choose your preferred method of communication. * Email * Parent or Guardian Responsible for Payment *
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Is (Parent or Guardian Responsible for Payment) address different from above? * Address (if different from above) * Employer's Name
Company Name
Employer's Address Is the patient covered by insurance? * -----------------------------------------------
List Additional Insurance? * Name *
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I authorize the following individual(s) to bring my child to his or her appointments:
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Please read each of the statements below:
I attest that the above named individual(s) are all 18 years of age or older as of this date.
I authorize the above named individual(s) to consent to treatment for the below named child. This may include, but is not limited to, consent for necessary medications, procedures, and hospitalization. Browning Medical Group may relay any medical information necessary for the about name individual(s) to provided informed consent for treatment.
I understand that a well child visit, vaccinations and sports physicals will require a parent or legal guardian present.
I understand that a well child visit, vaccinations and sports physicals will require a parent or legal guardian present.
I understand that Browning Medical Group will communicate their findings and treatment plan to the caregiver who brings the child, and that under most circumstances a follow-up call to me personally should not be necessary. I agree to be responsible for any fees for service requested by the above-named individual(s).
I agree to hold Browning Medical Group and its staff harmless for any disagreement between the above named individual(s) and me regarding treatment decisions.
I attest that I am the parent or legal guardian of the following children and that I have the legal authority to make this agreement. I understand that I can revoke the authorization for any of all these individual(s) at any time. Revocation must be submitted in writing.
I authorize the above named individual(s) to consent to treatment for the below named child. This may include, but is not limited to, consent for necessary medications, procedures, and hospitalization. Browning Medical Group may relay any medical information necessary for the about name individual(s) to provided informed consent for treatment.
I understand that a well child visit, vaccinations and sports physicals will require a parent or legal guardian present.
I understand that a well child visit, vaccinations and sports physicals will require a parent or legal guardian present.
I understand that Browning Medical Group will communicate their findings and treatment plan to the caregiver who brings the child, and that under most circumstances a follow-up call to me personally should not be necessary. I agree to be responsible for any fees for service requested by the above-named individual(s).
I agree to hold Browning Medical Group and its staff harmless for any disagreement between the above named individual(s) and me regarding treatment decisions.
I attest that I am the parent or legal guardian of the following children and that I have the legal authority to make this agreement. I understand that I can revoke the authorization for any of all these individual(s) at any time. Revocation must be submitted in writing.
I confirm that I have read the above Alternative Caregiver Consent Information above. * Children covered by this Consent:
Patient's Name *
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Parent/Guardian's Name: *
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NEW / ANNUAL PATIENT QUESTIONNAIRE
MEDICAL HISTORY List all of your child’s medications, including frequency and dosage (including over-the-counter medications, vitamins/supplements, and alternative therapies) or write none: *
Please list any medical problems, past or present, that your child has been treated for by a medical provider (examples: asthma, allergies, ADHD, congenital malformations, diabetes) or write none: *
Please list any surgeries and/or hospitalizations with approximate dates: (or write none) *
Please check any illnesses, if known, pertaining to the relatives listed below:
Birth Mother's Medical History * Birth Father's Medical History *
SOCIAL HISTORY Please list all people included in your household that child lives with:
Does anyone that lives in the child’s home smoke? * Are there pets in the home? * If yes, what kinds and how many? *
Please list on average the number of hours per day your child spends doing the following activities:
Please list anything else that you would us to know about your child:
AUTHORIZATION TO RELEASE MEDICAL RECORDS
Patient Information: Name *
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Record Requested From: Address
Record to be Sent to: Browning Medical Group
Records Requested: * Purpose:
Parent / Guardian Signature: Consent *
I agree to the following: I hearby certify that I am:
Disclosure: I understand that my health care provider cannot guarantee that the recipient will not redisclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information. 