Healthcare PEDS Add-On Form

HEALTHCARE PEDS ADD-ON FORM

Patient Information

Patient Name:

Date of Birth:    Gender:

Primary Phone:    Alternate Phone:

Guardian / Responsible Party

Guardian Name:

Relationship to Patient:

Guardian Phone:    Email:

Insurance Information

Policy / ID Number:    Group Number:

Subscriber Name:

Add-On Services Requested

Check all add-on services being requested for the patient as part of this visit or episode of care.

Vaccination / Immunization administration
Laboratory testing (blood, urine, point-of-care)
Newborn metabolic/hearing screening
Developmental / behavioral screening (PEDS tool)
Vision / hearing screening
Minor procedure or wound care (describe below)
Telehealth consultation add-on

Clinical Indication and Details

Requested By (Clinician Name):

Medical History

Allergies & Adverse Reactions

Risks, Benefits, and Authorization

I understand that the requested add-on services are medically indicated as described above. I acknowledge that the clinician has explained the nature, expected benefits, and reasonably foreseeable risks associated with each selected add-on service. I understand that not all risks can be anticipated and that complications may occur.

I authorize clinicians and staff to perform the selected add-on services and any clinically necessary ancillary care related to those services, including but not limited to specimen collection, administration of routine vaccines, point-of-care testing, minor wound care, and emergency stabilization if an unexpected adverse event occurs.

Financial Responsibility: I understand that add-on services may result in additional charges. I accept responsibility for any co-payments, co-insurance, deductibles, or amounts not covered by insurance. I authorize release of necessary information to my insurer for billing and payment.

Right to Decline or Withdraw: I acknowledge that I may decline or withdraw consent for any or all add-on services at any time prior to the service being performed, except when emergency treatment is required for the safety of the patient.

HIPAA / Privacy Acknowledgment

By signing below I acknowledge that I have been provided with or offered the facility's Notice of Privacy Practices and that I consent to the use and disclosure of protected health information as necessary for treatment, payment, and healthcare operations in connection with the requested add-on services.

Authorization Duration and Revocation

This authorization for add-on services is effective for the date of signature and any services provided during the current episode of care unless otherwise specified below.

Expiration Date (optional):

Certification

I certify under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge. I understand that falsification or omission of relevant medical information may adversely affect treatment and may result in administrative action.

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