Sweta test

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Patient Information

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Is the patient 18 years or older? *

Patient's Name *

First

Last

Patient's DOB *

Place of birth *

First

Last

Patient's Gender *

A-Number (if available)

Your Phone Number *

Your Email *

Address *

Address Line 1

City

State

Zip Code

1. Do you have any past or present medical conditions, chronic illnesses or mental illnesses? *

1. Does the patient have any past or present medical conditions, chronic illnesses or mental illnesses? *

Please list them here *

2. Have you had any surgeries and/or hospitalizations? *

2. Has the patient had any surgeries and/or hospitalizations? *

Please list reasons and dates of surgeries and/or hospitalizations *

3. Do you have any allergies? *

3. Does the patient have any allergies? *

Please list all allergies *

4. Do you take any medications? *

4. Does the patient take any medications? *

Please list all medications *

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Parent or Legal Guardian’s information

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How many parents? *

Patient's parents are? *

Please specify *

Who has custody? *

Name of the parent with sole custody *

First

Last

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First Parent

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Parent's Name *

First

Last

Parent's DOB *

Parent's Gender *

This parent is *

Phone *

Email *

Parent's Address *

Address Line 1

City

State

Zip Code

First Parent

This parent is the insurance subscriber

_______________________________________________________

Second Parent

_______________________________________________________

Second Parent's Name *

First

Last

Second Parent's DOB *

Second Parent's Gender *

This parent is *

Second Parent's Phone *

Second Parent's Email *

Second Parent's Address *

Address Line 1

City

State

Zip Code

Second Parent

This parent is the insurance subscriber

Name of the parent who the patient lives with? *

First

Last

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SIGNATURES by Patient or Legal Guardian

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Privacy Statement

We take your privacy seriously. Your information will NEVER be sold to, or shared with anyone outside of our HIPAA certified clinical team, website and billing departments. I understand that despite the clinic’s best efforts, due to the online nature of this form, it is not a completely secure form of communication and my protected health information may be put at risk of breach of data. It is with this knowledge that I complete this form. I do not hold San Fernando Pediatrics & Urgent Care or their employees and representatives responsible for any breach of data. I understand that I have the option to provide these information in person or by fax, which are more secured forms of communication.

Privacy Statement: We take your privacy seriously. Your information will NEVER be sold to, or shared with anyone outside of our HIPAA certified clinical team, website and billing departments. I understand that despite the clinic's best efforts, due to the online nature of this form, it is not a completely secure form of communication and my protected health information may be put at risk of breach of data. It is with this knowledge that I complete this form. I do not hold San Fernando Pediatrics & Urgent Care or their employees and representatives responsible for any breach of data. I understand that I have the option to provide these information in person or by fax, which are more secured forms of communication. *

Clear Signature

Signature of patient or legal guardian

Non-Covered Services Waiver

We pride ourselves on providing only the highest quality care for you and your children. We do this by following many of the American Academy of Pediatrics and other trusted sources for evidenced-based clinical outcome information. However, insurers rarely keep pace with guidelines, or want to cover services related to meeting these clinical recommendations. In fact, insurance company rules and policies change all the time. As prompt and appropriate treatment of your child is of primary importance to us, we ask that you sign a ‘waiver’ giving us permission to perform screenings, tests and non-covered services as we, your trusted providers of care, deem necessary. The following is a list of the most frequently provided services for which we request a signed waiver and that you can use to determine coverage with your insurer.

Vision Screening Test ($10.00): Snellen vision screening is a simple test performed with the use of a Snellen eye chart used to measure visual acuity on older children and adults. As we consider this to be an important test for your child, and will routinely perform them at annual well visits, if your insurer does not cover the charge, we will significantly discount the amount for you to $10.00 per test.

Audiometry Hearing Screening Test ($45.00): Hearing screen is an important test that is done each year, starting at the age of 4. It is also required for most preschools, public and private schools, and for sports physicals. If your insurance does not cover the charge, we will significantly discount the amount for you to $45.00 for both ears.

Ear Piercing ($99.00) We offer medical grade ear piercing offered to adults and pediatrics using only sterile medically safe materials that is only available through a medical professional. which is not a covered service by your insurance company. This service is not covered by insurance and costs a one-time charge of $99.00, which includes: A pair of sterile earrings with back, Topical anesthetic, Piercing procedure, Aftercare instructions, and piercing aftercare kit. In-office lab tests Often, patients want to know as soon as possible if their child has the flu, strep, etc. We can effectively and efficiently determine that by performing in-office testing. Many insurers do not pay for in-office testing because they have contracts with external labs to provide these services. However, sending tests out to external labs results in waiting days for results that we can provide to you much more quickly (in some cases, within minutes or overnight). We believe it is important to treat your child as quickly as possible, and therefore offer these services in-office.

RSV test $35 * Rapid flu $25 * Rapid strep $25 * Mono test $25 * H. Pylori test $25 * Urinalysis (UA) $25 * UA & Pregnancy test $25 * Glucose check $25 * PPD (TB) test $35 * COVID-19 test $86 * Eye exam $35 * GI cocktail $10 * B12 injection $35 * Sports Physical $35 * Forms completion $35 * Benadryl injection $25 * Ace bandage $5 *

Non-Covered Services Waiver: We pride ourselves on providing only the highest quality care for you and your children. We do this by following many of the American Academy of Pediatrics and other trusted sources for evidenced-based clinical outcome information. However, insurers rarely keep pace with guidelines, or want to cover services related to meeting these clinical recommendations. In fact, insurance company rules and policies change all the time. As prompt and appropriate treatment of your child is of primary importance to us, we ask that you sign a ‘waiver’ giving us permission to perform screenings, tests and non-covered services as we, your trusted providers of care, deem necessary. The following is a list of the most frequently provided services for which we request a signed waiver and that you can use to determine coverage with your insurer. Many insurers do not pay for in-office testing because they have contracts with external labs to provide these services. However, sending tests out to external labs results in waiting days for results that we can provide to you much more quickly (in some cases, within minutes or overnight). We believe it is important to treat your child as quickly as possible, and therefore offer these services in-office. Vision Screening Test $10 * Audiometry Hearing Screening Test $45 * Ear Piercing $99.RSV test $35 * Rapid flu $25 * Rapid strep $25 * Mono test $25 * H. Pylori test $25 * Urinalysis (UA) $25 * UA & Pregnancy test $25 * Glucose check $25 * PPD (TB) test $35 * COVID-19 test $86 * Eye exam $35 * GI cocktail $10 * B12 injection $35 * Sports Physical $35 * Forms completion $35 * Benadryl injection $25 * Ace bandage $5 *. I acknowledge receipt of the non-covered services waiver list and have been informed of, and hereby attest that I fully understand my financial responsibility for any balance resulting from non-covered services, or services not covered in-office, by my insurer. I agree to pay the amount of the charge as stated herein, in the event that my insurer does not cover these services. *

Clear Signature

Signature of patient or legal guardian

Financial Policy

San Fernando Pediatrics & Urgent Care participates with most insurance plans. Each insurance policy is different and it is therefore impossible for us to know what your particular benefits may be. Therefore, it is important to contact your insurance company if you have any questions regarding your benefits so that you are aware of your payment obligations at the time of service.

Copayments and Deductibles: Depending on your insurance policy, a co-payment and/or deductible may be required at the time of service. These payments are expected to be made at the time of service. Payment may be made in cash, or by credit or debit card. We also accept Health Savings Account (HSA) cards for payment. Please note that your co-payment is a contractual requirement from the insurance company and cannot be written off by the clinic. If you participate in a High Deductible Health Plan (HDHP) and have not yet paid or met your deductible in full, it is likely that any non-preventive services will require payment at the time those services are rendered. Please ensure that if you are unable to bring your child in by yourself, whomever brings the child, is prepared to make all payments.

Patients Without Insurance Coverage: We are happy to work with families that prefer to pay directly for services. For such patients, a time of service discount is included in the bill that is paid on the day of service. Any procedures or treatment that is provided is in addition to the office visit fee. All payments are due on the day of service.

No-Show & Same-Day Cancelation Fee:Missing an appointment without giving prior notice, deprives other patients of the chance to make an appointment for that time. We require a notice of at least 1 business day for all cancellations. Failure to notify the clinic in a timely manner will result in a no-show fee of $50 per individual patient appointment. Repeated no-shows will result in the family being advised to transfer care out of the practice.

Financial Policy: San Fernando Pediatrics & Urgent Care participates with most insurance plans. Each insurance policy is different and it is therefore impossible for us to know what your particular benefits may be. Therefore, it is important to contact your insurance company if you have any questions regarding your benefits so that you are aware of your payment obligations at the time of service. Copayments and Deductibles: Depending on your insurance policy, a co-payment and/or deductible may be required at the time of service. These payments are expected to be made at the time of service. Payment may be made in cash, or by credit or debit card. We also accept Health Savings Account (HSA) cards for payment. Please note that your co-payment is a contractual requirement from the insurance company and cannot be written off by the clinic. If you participate in a High Deductible Health Plan (HDHP) and have not yet paid or met your deductible in full, it is likely that any non-preventive services will require payment at the time those services are rendered. Please ensure that if you are unable to bring your child in by yourself, whoever brings the child, is prepared to make all payments. Patients Without Insurance Coverage: We are happy to work with families that prefer to pay directly for services. For such patients, a time of service discount is included in the bill that is paid on the day of service. Any procedures or treatment that is provided is in addition to the office visit fee. All payments are due on the day of service. No-Show & Same-Day Cancelation Fee: Missing an appointment without giving prior notice, deprives other patients of the chance to make an appointment for that time. We require a notice of at least 1 business day for all cancellations. Failure to notify the clinic in a timely manner will result in a no-show fee of $50 per individual patient appointment. Repeated no-shows will result in the family being advised to transfer care out of the practice. I acknowledge the receipt of and agree with San Fernando Pediatrics & Urgent Care Financial Policy. *

Clear Signature

Signature of patient or legal guardian

Authorization to Treat and Bill & Assignment of Benefits

I have read, understood and agree with the above financial policies. I consent to be treated by San Fernando Pediatrics & Urgent Care and any provider at this clinic. If I am not the patient, I am authorized to consent to treatment and billing for the patient identified below. I authorize San Fernando Pediatrics & Urgent Care, to bill my medical insurance for the care I receive and to release any information the insurance carrier requires to process this claim/bill. I authorize payment of medical benefits to San Fernando Pediatrics & Urgent Care. I understand that I am responsible for all charges for the treatment I receive. I understand that if I do not provide accurate and complete insurance information, San Fernando Pediatrics and Urgent Care may not receive payment from my carrier and I will be entirely responsible for my bill. Even after my medical insurance pays San Fernando Pediatrics & Urgent Care, I may owe payment for services not covered by my insurance and I agree to pay these promptly and no later than in 30 days. I understand that San Fernando Pediatrics & Urgent Care may send lab specimens to an outside laboratory (QuestDiagnostics, LabCorp, PrimexLabs, or WestPacLabs). I authorize any lab performing services for me to bill my medical insurance for their services. I understand that my medical insurance may not pay for all services provided by the lab and I agree to pay any remaining balance promptly to any outside lab providing services to me. I understand that San Fernando Pediatrics & Urgent Care is not responsible for payment to outside labs for tests provided to me unless I pay for these services directly to San Fernando Pediatrics & Urgent Care on the day of service. To protect my privacy and prevent fraud, I understand that if I cannot provide acceptable photo identification at the time of service, San Fernando Pediatrics & Urgent Care may choose not to bill insurance and may decline to accept credit/debit cards or checks as a form of payment. I understand that if I fail to pay San Fernando Pediatrics & Urgent Care for services provided to me, the balance owed will be sent to collections and I will incur collections fees of 35% in addition to the amount owed for services/treatment rendered. I understand that I may contact San Fernando Pediatrics & Urgent Care to work out payment arrangements that may prevent this additional cost.

All professional services rendered are charged to the patient and are due at the time of service, unless insurance coverage is verified and San Fernando Pediatrics & Urgent Care is a participating provider. Necessary forms will be completed to file for insurance carrier payments.

Assignment of Benefits: I hereby assign all medical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including private insurance and any other health/medical plan, to issue payment check(s) directly to San Fernando Pediatrics & Urgent Care for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.

Authorization to Release Information: I hereby authorize San Fernando Pediatrics & Urgent Care to: (1) release any information necessary to insurance carriers regarding myself and/or my dependent’s illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims. This order will remain in effect until revoked by me in writing. I have requested medical services from San Fernando Pediatrics & Urgent Care on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized. I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges (copay, coinsurance and/or deductible) incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.

Authorization to Treat and Bill & Assignment of Benefits: I have read, understood and agree with the above financial policies. I consent to be treated by San Fernando Pediatrics & Urgent Care and any provider at this clinic. If I am not the patient, I am authorized to consent to treatment and billing for the patient identified below. I authorize San Fernando Pediatrics & Urgent Care, to bill my medical insurance for the care I receive and to release any information the insurance carrier requires to process this claim/bill. I authorize payment of medical benefits to San Fernando Pediatrics & Urgent Care. I understand that I am responsible for all charges for the treatment I receive. I understand that if I do not provide accurate and complete insurance information, San Fernando Pediatrics and Urgent Care may not receive payment from my carrier and I will be entirely responsible for my bill. Even after my medical insurance pays San Fernando Pediatrics & Urgent Care, I may owe payment for services not covered by my insurance and I agree to pay these promptly and no later than in 30 days. I understand that San Fernando Pediatrics & Urgent Care may send lab specimens to an outside laboratory (QuestDiagnostics, LabCorp, PrimexLabs, or WestPacLabs). I authorize any lab performing services for me to bill my medical insurance for their services. I understand that my medical insurance may not pay for all services provided by the lab and I agree to pay any remaining balance promptly to any outside lab providing services to me. I understand that San Fernando Pediatrics & Urgent Care is not responsible for payment to outside labs for tests provided to me unless I pay for these services directly to San Fernando Pediatrics & Urgent Care on the day of service. To protect my privacy and prevent fraud, I understand that if I cannot provide acceptable photo identification at the time of service, San Fernando Pediatrics & Urgent Care may choose not to bill insurance and may decline to accept credit/debit cards or checks as a form of payment. I understand that if I fail to pay San Fernando Pediatrics & Urgent Care for services provided to me, the balance owed will be sent to collections and I will incur collections fees of 35% in addition to the amount owed for services/treatment rendered. I understand that I may contact San Fernando Pediatrics & Urgent Care to work out payment arrangements that may prevent this additional cost. All professional services rendered are charged to the patient and are due at the time of service, unless insurance coverage is verified and San Fernando Pediatrics & Urgent Care is a participating provider. Necessary forms will be completed to file for insurance carrier payments. Assignment of Benefits: I hereby assign all medical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including private insurance and any other health/medical plan, to issue payment check(s) directly to San Fernando Pediatrics & Urgent Care for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance. Authorization to Release Information: I hereby authorize San Fernando Pediatrics & Urgent Care to: (1) release any information necessary to insurance carriers regarding myself and/or my dependent's illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims. This order will remain in effect until revoked by me in writing. I have requested medical services from San Fernando Pediatrics & Urgent Care on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized. I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges (copay, coinsurance and/or deductible) incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original. I acknowledge the receipt of and agree with San Fernando Pediatrics & Urgent Care Authorization to Bill & Assignment of Benefits. *

Clear Signature

Signature of patient or legal guardian

Credit Card on File

In order to collect your portion of the bill once your insurance company processes the claim, it is our policy to have a valid credit card secured on file with the practice. Your card will only be charged the outstanding amount that your insurance company determines to be ‘patient responsibility’, as spelled out in your Explanation Of Benefits (EOB) in addition to non-covered expenses under your policy. Once your card is charged, a receipt may be sent to you by email or text to your mobile phone per your request. I understand and agree that all credit card chargebacks (credit card disputes) will incur a $50 administrative fee in addition to late fee and collections fee. Late fee is calculated at 15% per month. Collections fee is calculated at 35% of total amount.

Credit Card on File: In order to collect your portion of the bill once your insurance company processes the claim, it is our policy to have a valid credit card secured on file with the practice. Your card will only be charged the outstanding amount that your insurance company determines to be ‘patient responsibility’, as spelled out in your Explanation Of Benefits (EOB) in addition to non-covered expenses under your policy. Once your card is charged, a receipt may be sent to you by email or text to your mobile phone per your request. Last four digits of the credit card number on file. I agree to place this valid credit card on file with and authorize San Fernando Pediatrics & Urgent Care to charge my credit card with the amount due on the day of service and for whatever amount my insurance company determines as patient responsibility or non-covered services. Last 4 digits of the Credit Card on file: ____________. Expiration: ____________. I understand and agree that all credit card chargebacks (credit card disputes) will incur a $50 administrative fee in addition to late fee and collections fee. Late fee is calculated at 15% per month. Collections fee is calculated at 35% of total amount. *

Clear Signature

Signature of patient or legal guardian

PHYSICIAN-PATIENT ARBITRATION AGREEMENT

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by the law of the state of jurisdiction, and not by a lawsuit or resort to court process except as the law of the state of jurisdiction provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Article 2: All Claims Must Be Arbitrated: It is the intention of the parties that this agreement shall cover all claims or controversies whether in tort, contract or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to treatment or services provided or not provided by the below identified physician, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers (hereinafter collectively referred to as “Physician”) to a patient, including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children. Filing by Physician of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against Physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration. Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing by U.S. mail, postage prepaid, to all parties, describing the claim against Physician, the amount of damages sought, and the names, addresses and telephone numbers of the patient, and (if applicable) his/her attorney. The parties shall thereafter select a neutral arbitrator who was previously a California superior court judge, to preside over the matter. Both parties shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the arbitrator. Patient shall pursue his/ her claims with reasonable diligence, and the arbitration shall be governed pursuant to Code of Civil Procedure §§ 1280-1295 and the Federal Arbitration Act (9 U.S.C. §§ 1-4). The parties shall bear their own costs, fees and expenses, along with a pro rata share of the neutral arbitrator’s fees and expenses. Article 4: Retroactive Effect: The patient intends this agreement to cover all services rendered by Physician not only after the date it is signed (including, but not limited to, emergency treatment), but also before it was signed as well. Article 5: Revocation: This agreement may be revoked by written notice delivered to Physician within 30 days of signature and if not revoked will govern all medical services received by the patient. Article 6: Severability Provision: In the event any provision(s) of this Agreement is declared void and/or unenforceable, such provision(s) shall be deemed severed therefrom and the remainder of the Agreement enforced in accordance with the law of the state of jurisdiction. I understand that I have the right to receive a copy of this agreement. By my signature below, I acknowledge that I have received a copy and I acknowledge to have been given enough time to read this agreement and given time to ask questions. By my signature below I attest that I understand and agree with this arbitration agreement. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

PHYSICIAN-PATIENT ARBITRATION AGaREEMENT. Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by the law of the state of jurisdiction, and not by a lawsuit or resort to court process except as the law of the state of jurisdiction provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Article 2: All Claims Must Be Arbitrated: It is the intention of the parties that this agreement shall cover all claims or controversies whether in tort, contract or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to treatment or services provided or not provided by ALI ANARI MD INC DBA SAN FERNANDO PEDIATRICS & URGENT CARE, the below identified physician, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers (hereinafter collectively referred to as “Physician”) to a patient, including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children. Filing by Physician of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against Physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration. Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing by U.S. mail, postage prepaid, to all parties, describing the claim against Physician, the amount of damages sought, and the names, addresses and telephone numbers of the patient, and (if applicable) his/her attorney. The parties shall thereafter select a neutral arbitrator who was previously a California superior court judge, to preside over the matter. Both parties shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the arbitrator. Patient shall pursue his/ her claims with reasonable diligence, and the arbitration shall be governed pursuant to Code of Civil Procedure §§ 1280-1295 and the Federal Arbitration Act (9 U.S.C. §§ 1-4). The parties shall bear their own costs, fees and expenses, along with a pro rata share of the neutral arbitrator’s fees and expenses. Article 4: Retroactive Effect: The patient intends this agreement to cover all services rendered by Physician not only after the date it is signed (including, but not limited to, emergency treatment), but also before it was signed as well. Article 5: Revocation: This agreement may be revoked by written notice delivered to Physician within 30 days of signature and if not revoked will govern all medical services received by the patient. Article 6: Severability Provision: In the event any provision(s) of this Agreement is declared void and/or unenforceable, such provision(s) shall be deemed severed therefrom and the remainder of the Agreement enforced in accordance with the law of the state of jurisdiction. I understand that I have the right to receive a copy of this agreement. By my signature below, I acknowledge that I have received a copy and I acknowledge to have been given enough time to read this agreement and given time to ask questions. After reading this agreement, I understand and agree with this arbitration agreement. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. The Physician:________________________________. Signature of the Physician:_______________________________. Date:___________________________. *

Clear Signature

Signature of patient or legal guardian

Patient's Name *

First

Last

Parent or legal guardian's Name *

First

Last

Today's Date *

How did you hear about us? *

What is the name of the Lawyer? *

How did you hear about us? (specify) *

How fast do you need your files completed? *

There is an extra fee for faster initial lab and document processing time. Additional processing time may be required with positive test results. This fee is not refundable.

Form of Payment *

Credit Card
Debit Card
HSA Card
Cash

Total

$0.00

Stripe Credit Card *

YOUR SIGNATURE MUST MATCH YOUR ID

I AGREE TO PAY THE ABOVE AMOUNT ACCORDING TO MY CARD HOLDER AGREEMENT.

I AGREE TO PAY THE ABOVE AMOUNT ACCORDING TO MY CARD HOLDER AGREEMENT. Credit Card on File: In order to collect your portion of the bill once your insurance company processes the claim, it is our policy to have a valid credit card secured on file with the practice. Your card will only be charged the outstanding amount that your insurance company determines to be ‘patient responsibility’, as spelled out in your Explanation Of Benefits (EOB) in addition to non-covered expenses under your policy. Once your card is charged, a receipt may be sent to you by email or text to your mobile phone upon your request. I agree to place this valid credit card on file with and authorize San Fernando Pediatrics & Urgent Care to charge or debit my credit card with the amount due on the day of service and for whatever amount my insurance company determines as patient responsibility or non-covered services. Last 4 digits of the Credit Card on file: ____________. Expiration: ____________. I understand and agree that all credit card chargebacks (credit card disputes) will incur a $50 administrative fee in addition to late fee and collections fee. Late fee is calculated at 15% per month. Collections fee is calculated at 35% of total amount. *

Clear Signature

Signature

By pressing confirm, I understand that my insurance is not being billed, and by signing this form, I agree to pay San Fernando Pediatrics & Urgent Care the full balance of my bill for the office visit and procedures provided to me today. I, the undersigned, authorize San Fernando Pediatrics & Urgent Care to charge or debit my credit card on file for all outstanding balances due for the visit and services that I and those whom I am financially responsible for received, after my insurance is processed. I understand and agree that all credit card chargebacks (credit card disputes) will incur a $50 administrative fee in addition to late fee and collections fee. Late fee is calculated at 15% per month. Collections fee is calculated at 35% of total amount. I agree to San Fernando Pediatrics & Urgent Care’s terms of service, financial policy, cancelation policy, privacy policy and arbitration agreement posted on SanFernandoPediatrics.com

By pressing confirm, I agree to San Fernando Pediatrics & Urgent Care's terms of service, financial policy, cancelation policy, privacy policy and arbitration agreement posted on sanfernandopediatrics.com. By signing this form, I understand that San Fernando Pediatrics & Urgent Care is accepting me as a private-pay patient, and I am paying for the services I receive. The physician will not file a claim to my insurance for the services provided for me. PHYSICIAN-PATIENT ARBITRATION AGaREEMENT. Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by the law of the state of jurisdiction, and not by a lawsuit or resort to court process except as the law of the state of jurisdiction provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Article 2: All Claims Must Be Arbitrated: It is the intention of the parties that this agreement shall cover all claims or controversies whether in tort, contract or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to treatment or services provided or not provided by ALI ANARI MD INC DBA SAN FERNANDO PEDIATRICS & URGENT CARE, the below identified physician, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers (hereinafter collectively referred to as “Physician”) to a patient, including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children. Filing by Physician of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against Physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration. Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing by U.S. mail, postage prepaid, to all parties, describing the claim against Physician, the amount of damages sought, and the names, addresses and telephone numbers of the patient, and (if applicable) his/her attorney. The parties shall thereafter select a neutral arbitrator who was previously a California superior court judge, to preside over the matter. Both parties shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the arbitrator. Patient shall pursue his/ her claims with reasonable diligence, and the arbitration shall be governed pursuant to Code of Civil Procedure §§ 1280-1295 and the Federal Arbitration Act (9 U.S.C. §§ 1-4). The parties shall bear their own costs, fees and expenses, along with a pro rata share of the neutral arbitrator’s fees and expenses. Article 4: Retroactive Effect: The patient intends this agreement to cover all services rendered by Physician not only after the date it is signed (including, but not limited to, emergency treatment), but also before it was signed as well. Article 5: Revocation: This agreement may be revoked by written notice delivered to Physician within 30 days of signature and if not revoked will govern all medical services received by the patient. Article 6: Severability Provision: In the event any provision(s) of this Agreement is declared void and/or unenforceable, such provision(s) shall be deemed severed therefrom and the remainder of the Agreement enforced in accordance with the law of the state of jurisdiction. I understand that I have the right to receive a copy of this agreement. By my signature below, I acknowledge that I have received a copy and I acknowledge to have been given enough time to read this agreement and given time to ask questions. After reading this agreement, I understand and agree with this arbitration agreement. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. The Physician:________________________________. Signature of the Physician:_______________________________. Date:___________________________. I understand and agree that all credit card chargebacks (credit card disputes) will incur a $50 administrative fee in addition to late fee and collections fee. Late fee is calculated at 15% per month. Collections fee is calculated at 35% of total amount. I agree to San Fernando Pediatrics & Urgent Care's terms of service, financial policy, cancelation policy, privacy policy and arbitration agreement posted on SanFernandoPediatrics.com *

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