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5300 W Hillsboro Blvd, Suite 110 Coconut Creek, FL 33073 (954) 794-1360 off (954) 794-1367 fax

PATIENT HISTORY HISTÓRICO DO PACIENTE

Last Name:______________________ First Name:___________________ Date:_________ Sobrenome: ______________________ Primeiro nome: ________________ Data:_________ Date of Birth:__________________Sex:________ Phone:_________________________ Data de Nascimento: ______________ Sexo:___________Número de Telefone:_________________ PAST MEDICAL HISTORY - HISTÓRICO MÉDICO NO YES Serious injuries or accidents Ferimentos sérios ou acidentes NO YES Surgeries Cirurgias NO YES Hospitalizations Hospitalizações NO YES Chickenpox Catapora NO YES Frequent ear infections or sinus infections Infecções de ouvido frequentes ou sinusite NO YES Pharyngitis/ tonsillitis Faringite / amigdalite NO YES Other infectious illnesses Outras doenças infecciosas NO YES Allergic rhinitis or other allergy Rinite alérgica ou outra alergia NO YES Allergy to animals Alergia á animais NO YES Outdoor allergens Reações a alérgenos do ar livre NO YES Indoor allergens Reação a alérgenos de interiores NO YES Asthma, bronchiolitis, bronchitis, pneumonia or croup Asma, bronquiolite, bronquite, pneumonia ou crupe NO YES Heart problems or heart murmur Problemas no coração ou sopro cardíaco NO YES Abdominal pain/GER Dor abdominal / Doeça do refluxo gastroesofágico (DRGE) NO YES Constipation requiring doctor visits Constipação que requeira visita médica

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NO YES Bladder or kidney infection or other urologic problem Infecção de bexiga ou rim ou outro problema urológico NO YES Bed-wetting (after 5 years of age) Urina na cama (depois dos 5 anos de idade) NO YES Eye conditions/ corrective lenses Problema de visão / lente de contato corretiva NO YES Problems with ears or hearing Problemas com os ouvidos ou audição NO YES Chronic or recurrent skin problems (acne, eczema, etc) Problema de pele recorrente ou crônico (acne, eczema, etc) NO YES Anemia or bleeding problem Anemia ou problema de sangramento NO YES Blood transfusion Transfusão de sangue NO YES Frequent headaches Dores de cabeça frequentes NO YES Seizures, developmental delays, ADD/ADHD or other neurologic disorder Convulsões, atrasos de desenvolvimento, DDA / TDAH ou outro problema neurológico NO YES Mental health concerns Saúde mental comprometida NO YES Orthopedic problems Problemas ortopédicos NO YES Diabetes Diabetes NO YES Thyroid or other endocrine problems Tiróide ou outros problemas endocrinológicos NO YES If female, have menstrual periods started? Se mulher, já entrou no período menstrual? NO YES If female, any problems with periods? Se mulher, tem algum problema com a menstruação? NO YES Use of alcohol or drugs Uso de álcool ou drogas NO YES Emotional problems Problemas emocionais NO YES Other significant problems Outros problemas significativos FAMILY MEDICAL HISTORY HISTÓRICO MÉDICO DA FAMÍLIA NO YES Nasal allergies or other allergies, WHO: ________________________ Alergias nasais ou outras alergias, QUEM NO YES Asthma/lung disease, WHO: _________________________________ Asma/ doença de pulmão, QUEM NO YES Heart disease or heart condition, WHO: ________________________ Doenças do coração ou problemas cardíacos, QUEM NO YES High blood pressure, WHO: _________________________________ Pressão alta, QUEM NO YES High cholesterol, WHO:_____________________________________

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Colesterol alto, QUEM NO YES Diabetes, WHO: ___________________________________________ Diabetes, QUEM NO YES Cancer, WHO: ____________________________________________ Câncer, QUEM NO YES Anemia, WHO: ____________________________________________ Anemia, QUEM NO YES Bleeding disorder, WHO: ____________________________________ Distúrbio de sangramento, QUEM NO YES Epilepsy or convulsions, WHO: _______________________________ Epilepsia ou convulsões, QUEM NO YES Mental retardation, developmental delays or neurologic disorder including ADHD/ADD, WHO: _____________

Retardamento mental, atraso de desenvolvimento ou disordem neurológica incluindo TDAH/DDA, QUEM

NO YES Liver disease (hepatitis), WHO:____________________________ Doença de fígado (hepatite), QUEM NO YES Stomach or intestine disorders (gastritis/ulcers...), WHO:___________ Disordens de estômago ou intestino (gastrite/ úlceras..) QUEM NO YES Kidney disease (kidney stone), WHO:__________________________ Doença renal (pedra nos rins), QUEM NO YES Bed-wetting (after 10 years old), WHO:_________________________ Urina na cama (depois dos 10 anos de idade) QUEM NO YES Hearing impairment, WHO:__________________________________ Deficiência auditiva, QUEM NO YES Vision impairment or eye disorder (myopia, astigmatism...), WHO:___ Deficiência visual ou disordem ocular (miopia, astigmatismo), QUEM NO YES Immune problems, infections or HIV/AIDS, WHO: _______________ Problema com imunidade, infeções ou HIV/AIDS, QUEM NO YES Alcohol abuse, WHO: _______________________________________ Abuso do álcool, QUEM NO YES Drug abuse, WHO:_________________________________________ Abuso de drogas, QUEM NO YES Mental illness, WHO: _______________________________________ Doenças mentais, QUEM NO YES Tuberculosis, WHO: ________________________________________ Tuberculose, QUEM NO YES Additional conditions_______________________________________ Condições adicionais SOCIAL HISTORY: HISTÓRICO SOCIAL Adopted? Yes No If yes at what age_____________________________________ Adotado (a) sim ou não, com qual idade ____________________________________ Lives with an intact family ___________________________________________ Mora com a família que nunca foi desmembrada Non intact custody status _____________________________________________ Status da custódia dos filhos Visitation Status of Non Custodial Parent ______________________________

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Status da visita do responsável que não tem a custódia Siblings ___________________________________________________________ Irmãos Pets ______________________________________________________________ Animais de estimação Smokers in the home _________________________________________________ Fumantes em casa Guns in the home _________________________________________________ Armas em casa Guns are locked and kept separate from ammunition _________________________ As armas estão trancadas e mantidas em local diferente da munição

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5300 W Hillsboro Blvd, Suite 110 Coconut Creek, FL 33073 (954) 794-1360 office (954) 794-1367 fax

PATIENT NAME: Birth Date: / /

Sex: F M SSN#: / / Language Spoken:

Lives with: Both Parents Mother Dad Other:

New Patient No Yes - How did you hear about our office:

Mother’s Name: DOB: / / SS#: / /

Address:

City: State: Zip Code: Home Phone #: ( ) -

Cell Phone #: ( ) - EMAIL ADDRESS:

Mother’s Employer: Work Phone #: ( ) -

Father’s Name: DOB: / / SS#: / /

Address:

City: State: Zip Code: Home Phone #: ( ) -

Cell Phone #: ( ) - EMAIL ADDRESS:

Father’s Employer: Work Phone #: ( ) -

EMERGENCY CONTACT INFORMATION

Emergency Contact (OUTSIDE household/not parents):

Relationship Phone: ( ) -

AUTHORIZATION AND RELEASE

I hereby acknowledge that I read the medical practice’s HIPPA-Notice of Privacy Practices. I hereby authorize and request my insurance company to pay directly to the physician benefits otherwise payable to me. I understand that my medical insurance may pay less that the actual bill for services rendered. I understand that I am financially responsible for all charges weather or not paid by insurance including all attorney fees and court cost incurred to enforce this obligation and to collect any unpaid charges.

I hereby authorize release of all medical information to:

Mother and Father Father only (must provide court documentation) Mother only (must provide court documentation)

Other: Relation ship:

Signature: Date / /

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FINANCIAL AGREEMENT and OFFICE POLICIES

1. Copay, deductible and non-covered services must be paid at the time of the service.

2. Any outstanding balances must be paid at the time of service unless other arrangements have been made with the financial office.

3. Parents of newborn patients applying to Commercial or State Sponsored Insurance will be required to

pay for all services at the time of the appointment. Parents must notify the billing office when insurance is active. Our office will then send all charges to the health plan. After services are paid by insurance our office will refund payments. Our office provides 7-week waiting period for newborn to be enrolled in a health plan. After 7-weeks, our office will NOT refund any payments made by parents and will NOT file any claims to health plan once this courtesy waiting period has expired.

4. If patient is health insurance (including Medicaid) is inactive services must be paid at time of visit. If

health plan activated at a later time, our office WILL NOT refund any payments or send services to health plan. We can provide a receipt and parent/guardian can request refund from his/her insurance.

5. In the event that your insurance (including Medicaid) denies any rendered services, parent/guardian will be

responsible for the payment of all charges.

6. We require 24-hour notice for canceling appointments. There is a $30 “no-show” fee for a missed sick appointment and $50 for an annual well exam. If patient has four or more “no-show” appointments, he/she might be asked to leave the practice.

7. If you arrive more than 15 minutes late for your appointment, you may, at the discretion of the physician,

be asked to reschedule the appointment. Please call ahead and inform us if you are running late. We will make every effort to fit you in, however, you will possibly have to wait until there is an opening in the schedule.

8. If your account is referred to an agency or attorney for collection, you will be responsible for all cost,

attorney fees, all court cost and interest of 1.5% per month. In the event that my insurance does not pay for services rendered or if there is an outstanding balance on my account, I hereby authorize ALL BETTER PEDIATRIC GROUP to charge the due amount to my credit card on file.

Credit Card Holder:

Credit Card Number:

Expiration: Zip Code:

I have read and understood the above Financial and Cancellation policies and agree this constitutes a contract between myself and ALL BETTER PEDIATRIC GROUP and its representatives.

/ / Signature Date

Print name Relationship to patient

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5300 W Hillsboro Blvd, Suite 110 Coconut Creek, FL 33073 (954) 794-1360 off (954) 794-1367 fax

LABORATORY OFFICE POLICY

If your insurance does not pay for any laboratory tests performed at our office, you will be responsible for the balance. Any outstanding balance must be paid prior to your next visit.

I have read and understand All Better Pediatric Group’s office policies and agree to comply with those policies.

Name of Child(ren)_ _DOB _

_ Print name and relationship to patient

Signature Date

Regras do consultorio

Se o seu seguro nao pagar pelos procedimentos de laboratorio feito no consultorio, voce sera responsavel pela conta. E a sua responsabilidade em pagar a conta na proxima consulta.

Eu li e entendi as regras do consultorio do Dr Renato Berger, e vou seguir-las.

Nome da Crianca(S)_ DOB

_ Nome do responsavel e a realacao ao paciente

_ Assinatura do responsavel Data

5300 W Hillsboro Blvd. Suite 110 Coconut Creek, FL 33073 (954) 794-1360 office (954) 794-1367 fax

NEWBORN POLICY

Patient Name: __________________________ Date of Birth:____________ I, __________________________________________________

Parent Name

Have submitted enrollment application to add my newborn child to a Commercial or State Sponsored Insurance (__________________________________) Will NOT enroll my child to any health insurance plan and will pay for all services I understand, All Better Pediatric Group will give newborn’s parent/guardian a seven-week courtesy waiting period (from date of birth ___/ ____/ ___) to obtain health insurance coverage. I will be responsible for providing All Better Pediatric Group my child’s health plan information (plan name and member ID) as soon as I am notified the health plan is active. I understand any balance due for services provided to my child at the hospital will be paid at the time of my first visit to the medical office. All office medical visits will be paid at the time of my child’s appointment until his/her health plan is active. If newborn is going to be enrolled to a commercial health plan and his/her sibling(s) is currently a patient of All Better Pediatric Group under same insurance health plan, parent/guardian will only be required to pay a $145 deposit that will be refunded after health plan has paid for all billed services. All Better Pediatric Group is responsible for filing medical charges to health plan when parent/guardian provides required information BEFORE the seven-week courtesy waiting period. After patient’s health plan has paid all medical charges, parent/guardian can request a refund of payments made. If health plan is activated AFTER the seven-week courtesy waiting period, All Better Pediatric Group will NOT send any previous medical charges to health plan and will NOT refund any payments made by parent/guardian prior to this time. I have reviewed the attached list of Health Plans accepted by All Better Pediatric Group. If my child is enrolled in a health plan not accepted by the office, I will be responsible for the payment of all outstanding charges. ____________________________ ______________________ _____________ Parent Name Parent Signature Date

Effective October 1, 2016

5300 W Hillsboro Blvd. Suite 110 Coconut Creek, FL 33073 (954) 794-1360 office (954) 794-1367 fax

SELF PAY PATIENTS

Patient Name: __________________________ Date of Birth:____________ I, __________________________________________________

Parent Name

I understand my child’s doctor visit today ____/_____/_____ will be as a Self-Pay patient. I understand that if any health insurance is activated after today’s visit, All Better Pediatric Group will NOT retroactively file claim(s) to my child’s insurance company for any services rendered or refund payment made for today’s visit. ____________________________ ______________________ _____________ Parent Name Parent Signature Date

PCMH HANDOUT & AGREEMENT

PCMH Agreement between All Better Pediatric Group and _______________________________

The signed agreement below indicates that I have understood that I will work together with my

Primary Care Provider before my appointment, during my appointment, and after my

appointment to strive towards Patient Centered Medical Home (PCMH). PCMH provides health

care that is relationship-based with an orientation toward the whole person. Partnering with patients

and their families requires understanding and respecting each patient’s unique needs, culture, values,

and preferences. The medical home practice actively supports patients in learning to manage and

organize their own care at the level the patient chooses. Recognizing that patients and families are core

members of the care team, medical home practices ensure that they are fully informed partners in

establishing care plans.

XParent/Guardian signature

XDate

REQUEST FOR MEDICAL RECORDS

TO DR.: _________________________________________________

Phone #: ________________________ FAX #: _______________

I, undersigned, hereby authorize All Better Pediatric Group to request the following information from my (relationship) _____________ medical records. This authorization includes release of information concerning HIV testing or treatment of AIDS, AIDS-related conditions, drug or alcohol abuse, and drug related conditions, alcoholism, and/ or psychiatric/psychological conditions. The following information may be release or reviewed: __ DISCHARGE SUMMARY __ OUTPATIENT CLINIC NOTES _X_ HISTORY & PHYSICAL EXAMINATION _X_ IMMUNIZATION (SHOT) RECORDS

__ OPERATIVE REPORT __ EMERGENCY DEPARTMENT RECORDS _X_ ALL RECORDS AND IMMUNIZATION RECORDS, PLEASE..!! THE ABOVE INFORMATION IS TO BE RELEASED TO:

ALL BETTER PEDIATRIC GROUP 5300 WEST HILLSBORO BLVD, SUITE 110

COCONUT CREEK, FL 33073 Phone: (954) 794-1360 Fax: (954)794-1367

The above information is requested to be release for the following purposes only

CHANGE OF PRIMARY CARE PHYSICIAN This statement must be signed and dated, and may be revoked at any time except in the extent action has been taken prior to revocation. This consent will expire (60) days after the date below, or sooner by my choice. I hereby state that I have read and fully understand the above statements as they apply to me. I hereby consent to the disclosure of treatment records to the purpose and extent stated above. PATIENT’S NAME: ______________________________________________ D.O.B.:________________ ADDRESS: ____________________________________________________________________________ ______________________________________________________________________________ SIGNATURE:_________________________________ RELATIONSHIP: _________________________ PHONE #.: _________________________________ DATE: ________________________________ * LEGAL GUARDIAN OF PATIENT MUST SIGN THE AUTHORIZATION BECAUSE HE/SHE IS AN EMANCIPATED MINOR OR THE CONDITIONS OF TREATMENT REQUIRE SIGNATURE.

5300 W Hillsboro Blvd., Suite 110 Coconut Creek, FL 33073 (954) 794-1360 office 954) 794-1367 fax

Email: webportal@allbetterpediatricgroup.com Website: www.allbetterpediatricgroup.com Patient Portal: https://portal.allbetterpediatricgroup.com

Dear Parent, We have exciting news regarding your health care! As we continue in our efforts to provide our patients with the highest quality of care, we are constantly looking for methods of working together with you to ensure that you are not only aware of but involved in the maintenace and improvement of your child's health.

To that end, we are proud to announce that our practice now offers a Patient Portal where you will be able to track all aspects of your child's health care. The Patient Portal enables our patients to communicate with our practice easily, safely, and securely, all from the comfort of your home, whenever it is convenient for you! Patient Portal: https://portal.allbetterpediatricgroup.com Username: e-mail address you have provided to our office. Temporary Password: _____________ From the Patient Portal you will be able to: View your child's office visits, growth chart, immunization records, laboratory results, prescribed medications and open balances.

Request appointments for annual well exams, prescription refills and school forms.

Print previously requested referrals, school forms (680/3040), WIC and medication authorization forms. Please allow 2 business days for your request to be ready. If you prefer to have us print the forms, there will be a charge of $5.00 per form.

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PCMH HANDOUT & AGREEMENT PCMH Agreement between All Better Pediatric Group and _______________________________

What is Patient Centered Medical Home (PCMH): PCMH is a care delivery model whereby patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand.

PCMH provides health care that is relationship-based with an orientation toward the whole person. Partnering with patients and their families requires understanding and respecting each patient’s unique needs, culture, values, and preferences. The medical home practice actively supports patients in learning to manage and organize their own care at the level the patient chooses. Recognizing that patients and families are core members of the care team, medical home practices ensure that they are fully informed partners in establishing care plans.

Purpose:

• To provide optimal health care for our patients

• To provide a framework for better communication and safe transitions of care between the primary care and specialty care providers

Principles:

• Effective communication between primary care and specialty care is key to providing optimal patient care and to eliminate the waste and excess costs of health care.

• Mutual respect is essential to building and sustaining a professional relationship and working collaboration

Definitions:

• Primary Care Physician (PCP) –a generalist whose broad medical knowledge provides first contact, comprehensive and continuous medical care to patients.

• Specialist –a physician with advanced, focused knowledge and skills who provides care for patients with complex problems in a specific organ system, class of diseases or type of patient.

• Transition of Care –an event that occurs when the medical care of a patient is assumed by another medical provider or facility such as a consultation, hospitalization, or transition to adult care.

• Co-management –where both primary care and specialty care providers actively contribute to the patient care for a medical condition and define their responsibilities including first contact for the patient, drug therapy, referral management, diagnostic testing, patient education, care teams, patient follow up, monitoring, as well as, management of other medical disorders.

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Patients/Parents/Guardian’s Responsibilities Patients/Parents/Guardians, YOU are the center of your healthcare team. As the most important team member, you are a full partner when it comes to your health care. It is your responsibility to give your team the information they need to do an excellent job. For your convenience, here are some checklists of things to do before, during and after your appointment!

Before your appointment:

• Gather all the medications you are currently taking, if at all possible. This includes prescription medicines and over-the-counter medicines such as aspirin or antacids, vitamins, dietary or herbal supplements. If bringing your medications is not possible, be sure to write down the name and how much you take of all your medications!

• Make a list of all the doctors and clinics you see and bring it with you.

• Write down all the questions you want to ask during your appointment. You might have questions about specific medicines, medical tests, procedures or surgeries, or lifestyle issues such as nutrition or exercise.

• List your questions so that the most important ones are at the top to ensure you’ll get the answers you need!

• Be prepared to provide information about your current medical conditions, past surgeries and illnesses, including dates. You’ll also want to be familiar with your family’s medical history. This information can be critical when it comes to providing you with the best possible care.

• Write down the names and contact information for all members of your team, and keep it upto-date. You’ll want to take the list with you to your appointment.

• Be familiar with your health insurance coverage, and contact your insurance provider if you have any questions about your benefits.

• Call to reschedule or cancel appointments as soon as possible.

During Your Appointment

• Show all of your medications, in their original, labeled containers, to your provider if possible. If bringing your medications is not possible, show the list you made with each your medication names and how you take it!

• Mention any home remedies you might have used to treat your condition(s).

• Give your list of all the doctors and clinics to your provider so we can sure to coordinate your care well. And request any pertinent records we may need to include in your patient chart.

• Make your health care provider aware of any changes in your health and your condition(s) since your last visit. Also tell us about changes in the health of any of your family members. It will help us take better care of you!

• Discuss your health issues and be sure you understand what you need to do for each one. Ask your health care provider which one(s) you should work on first.

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• Go through your list of questions, beginning with your most urgent or important ones. Be sure to ask how you can reach your care team after hours you might need your provider!

• Be sure you understand the instructions your provider gives you before you leave the office and follow instructions. We don’t mind repeating or using different words to explain!

After your appointment:

• Continue to learn about your condition(s) and what you can do to stay as healthy as possible.

• Follow the plan that you and your provider discussed. If you have ANY questions about your treatment plan, be sure to call us. We want you to understand how to take the best care of yourself.

• Take your medications as your provider ordered. If you and your provider agreed that you would stop certain medications including any supplements, vitamins or over-the-counter remedies, be sure to stop taking them! If you have ANY question about your medicines, be sure to call us.

• Call us if you haven’t received test results within the time your provider told you to expect your results.

• Comply with provider’s plans and instructions (Ex: Schedule follow up appointments, complete labs and imaging request, follow through with specialist referrals.) If provider plans and gives instructions are not followed through, you MUST let us know the reason why so your provider can adjust your care plan.

• Contact us after hours if your issue can’t wait until the regular office hours. We can still help direct your care. Call our normal office line (954-794-1360) and follow the prompts to be transferred to our after-hours operator. The provider will be contacted and will call you back as soon as they are available and will provide you with the next steps in your care.

• Pay your share of any fees for your care.

• Tell us how we are doing! We want to hear from you! You may receive a satisfaction survey in the mail. If you do, please fill it out and send it back! It will help us improve your care and make us better at what we do.

MEDICAI

D

MEDICAID HEALTHY

KIDS

MEDICAID MMA PLANS MEDICAID

SPECIALTY

MARKET PLACE

OBAMA CARE

COMMERCIAL INSURANCE PLANS

Full Wellcare/Staywell BetterHealth (Broward) CMS 19 Blue Cross Aetna

Aetna Better Health Community Care (Broward) CMS 21 Molina Avmed

Coventry (Miami-Dade) Magellan Assurant Health Cigna PPO

Molina (Palm Beach, Miami-Dade) Assurance Health

Simply Health Care (Miami-Dade) Blue Cross (except MY BLUE)

United (Miami-Dade) Cigna

WellCare (Miami-Dade, Palm Beach, Broward) Coventry

GMMI

Golden Rule

GreatWest

Harvard Pilgrim

Health Alliance

Humana

Humana Miliatry/Tricare

North Broward Hospital/Best Choice

Neighborhood

Oxford

UMR

United

Updated 12/1/2017

WE DO NOT PARTICIPATE WITH:

All Better Pediatric Group

5300 W Hillsbor Blvd.

Suite 110

Coconut Creek, FL 33073

AND ANY INTERNATIONAL POLICIES.

HUMANA MEDICAID

SUNSHINE

MY BLUE

TRICARE PRIME HMO