1 | P a g e
8650 Alameda Blvd NE
Suite 101E
Albuquerque, NM 87122
T (505) 255-1866
F (505) 255-1852
Patient Information
Patient Name: __________________________________________________________________ Date of Birth: ______ /______ /_______
Sex: ☐ M / ☐ F Patient SSN: ____________________________________________
Race: ☐ White ☐ Asian ☐ Black/African American ☐ Native American/Alaskan Native
Hispanic/Latino Ethnicity: ☐ Yes / ☐ No Language: ☐ English ☐ Spanish ☐ Other: __________
Mailing Address: ________________________________________________________________________________________________________
City: _____________________________________________________________________ State: ___________ Zip Code: ________________
Responsible Party Information
Parent/Guardian #1: __________________________________________________________________ DOB: _______________________
Relationship: _______________________________________________________________ Phone #: _______________________________
Email: _____________________________________________________________________________________________________________________
Parent/Guardian #2: __________________________________________________________________ DOB: _______________________
Relationship: _______________________________________________________________ Phone #: _______________________________
Email: _____________________________________________________________________________________________________________________
Pharmacy
Pharmacy Name: _________________________________________________________________ Phone: _____________________________
Address/Cross Streets: ________________________________________________________________________________________________
Consents
Call ☐ Yes ☐ No
Text ☐ Yes ☐ No
Email ☐ Yes ☐ No - Email: _______________________________________________________________________________________
Medication History Authority ☐ Yes ☐ No
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8650 Alameda Blvd NE
Suite 101E
Albuquerque, NM 87122
T (505) 255-1866
F (505) 255-1852
Billing / Insurance Information
(Please give your insurance card to the receptionist to copy)
*** If patient is Newborn, please provide Mom’s Insurance ***
Primary Insurance: _____________________________________________________________________________________________________
Subscriber/Policy Holder Name: __________________________________________________________ DOB: __________________
Subscriber/Policy Holder SSN: ____________________________________________________________
Secondary Insurance: __________________________________________________________________________________________________
Subscriber/Policy Holder Name: __________________________________________________________ DOB: __________________
Subscriber/Policy Holder SSN: ____________________________________________________________
Billing Address if Different than Patient’s
Billing Address: _________________________________________________________________________________________________________
City: ______________________________________________________________ State: ______________ Zip Code: ____________________
______________________________________________________________________________________________________________________________
I authorize the release of any medical information necessary to process this claim.
Signature (REQUIRED): ___________________________________________________________________ Date: ___________________
I authorize payment of medical benefits to High Desert Pediatrics for services provided.
Signature (REQUIRED): ___________________________________________________________________ Date: ___________________
3 | P a g e
8650 Alameda Blvd NE
Suite 101E
Albuquerque, NM 87122
T (505) 255-1866
F (505) 255-1852
Past Medical History
Patient Name: ___________________________________________________________ DOB: ______________
Please list allergies the patient may have:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Have you ever been hospitalized overnight? ☐ Yes ☐ No If so, when: ________________________________
Are immunizations up to date? ☐ Yes ☐ No (We would like a copy of immunization records)
Which of the following conditions is the patient currently being treated or has been treated for in the past?
☐ Heart disease/murmur
☐ Shortness of breath
☐ Eye disorder
☐ High cholesterol
☐ Asthma
☐ Seizures
☐ Low blood pressure
☐ Lung Problems
☐ Stroke
☐ High blood pressure
☐ Sinus problems
☐ Headaches/Migraines
☐ Heartburn/reflux
☐ Seasonal allergies
☐ Neurological problems
☐ Anemia/blood/bleeding
problems
☐ Tonsillitis
☐ Depression/Anxiety
☐ Pregnancy (prior history)
☐ Ear problems
☐ Psychiatric care
☐ Diabetes
☐ Kidney/Bladder problem
☐ Liver problems
☐ Arthritis
☐ Cancer
☐ Ulcers/Colitis
☐ Thyroid problem
☐ Sexually transmitted disease
☐ Abnormal pap smear
☐ Corrective lenses/glasses
☐ Hearing loss
☐ Rheumatic fever
☐ Hernia
☐ Kidney stones
☐ Eating disorder
Please describe any current or past medical treatment not listed above:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Please list your past surgeries: (Include tonsillectomy, adenoidectomy, PE tubes, dental surgery, appendectomy,
abdominal surgery (hernia)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
4 | P a g e
8650 Alameda Blvd NE
Suite 101E
Albuquerque, NM 87122
T (505) 255-1866
F (505) 255-1852
Family History
Living Age (or age at death) List serious illnesses
Mother ☐ Yes ☐ No ___________________ __________________
Father ☐ Yes ☐ No ___________________ __________________
Sister(s) ☐ Yes ☐ No ___________________ __________________
Brother(s) ☐ Yes ☐ No ___________________ __________________
Has any member of your family (including children and parents) had any of the following illnesses?
Illness Which Family Member? Side of Family?
Allergies ___________________________________ ☐ Maternal ☐ Paternal
Anemia/Blood Disease ___________________________________ ☐ Maternal ☐ Paternal
Asthma ___________________________________ ☐ Maternal ☐ Paternal
Bleeding Disorder ___________________________________ ☐ Maternal ☐ Paternal
Cancer ___________________________________ ☐ Maternal ☐ Paternal
Diabetes ___________________________________ ☐ Maternal ☐ Paternal
Glaucoma ___________________________________ ☐ Maternal ☐ Paternal
Heart Disease ___________________________________ ☐ Maternal ☐ Paternal
High Blood Pressure ___________________________________ ☐ Maternal ☐ Paternal
Lupus ___________________________________ ☐ Maternal ☐ Paternal
Mental Illness/Depression ___________________________________ ☐ Maternal ☐ Paternal
Stroke ___________________________________ ☐ Maternal ☐ Paternal
Other Serious Illness ___________________________________ ☐ Maternal ☐ Paternal
5 | P a g e
8650 Alameda Blvd NE
Suite 101E
Albuquerque, NM 87122
T (505) 255-1866
F (505) 255-1852
Assignment of Benefits & Financial Responsibility
Assignment of Benefits: I authorize that payment of insurance or other benefits be made on the
patient's behalf to High Desert Pediatrics and agree to assist in the processing of claims for benefits.
• IF YOU DO NOT HAVE INSURANCE: You are responsible and strictly liable for the prompt
payment of your bill, in total, at the time of your visit, before the patient is seen and any services
performed. We accept personal checks, credit cards, and cash. If you are unable to pay your bill in
full at the time of the visit, please ask to speak to our Billing Department prior to the time of
your visit.
• IF YOU HAVE COVERAGE WITH AN INSURANCE COMPANY WITH WHOM WE DO
NOT HAVE A CONTRACT: HIGH DESERT PEDIATRICS will, at your request, submit a claim
directly to your insurance company for reimbursement. Please review the following procedure and
initial.
“I understand that my services are being billed directly to my insurance carrier for me. The insurance
company should send payment directly to High Desert Pediatrics. If the payment is sent to me, I will forward
the payment to High Desert Pediatrics immediately. If payment is not received at High Desert Pediatrics
within 45 days, a statement will be sent to me. I understand that it is my responsibility to follow up with my
insurance company. I understand that the entire balance is always my responsibility and that I am strictly
liable for the entire amount of my balance and that I will pay the balance in full to High Desert Pediatrics
promptly if my insurance company does not timely do so.”
Parent/Guardian Initials: ________________
• IF YOU ARE A CUSTODIAL PARENT: By law, you are ultimately responsible for and strictly
liable for payment of your child’s medical bills, even if you are not the carrier of your child’s
insurance policy. Our legal agreement to care for your child is made with you only.
• COLLECTIONS: I understand and agree that fees and charges not paid in full by the patient or
insurance company may be placed with a collection agency for collection or be subject to legal action
(including attorney’s fees and interest) to recoup the unpaid fees. I consent to the use of any contact
information I give High Desert Pediatrics (including updated information) to be provided to the
collection agency on the patient’s account, and further consent to the use of technology, including
auto dialing, and the use of prerecorded messages on cellular/landline phones, in contacting me.
Patient Name: ___________________________________________________________________________ DOB: _______________________
Parent/Guardian Signature: __________________________________________________________________________________________
Today’s Date: ________________________
6 | P a g e
8650 Alameda Blvd NE
Suite 101E
Albuquerque, NM 87122
T (505) 255-1866
F (505) 255-1852
Immunization Policy Statement
Patient Name: ____________________________________________________________________ DOB: _____________________
The healthcare providers at High Desert Pediatrics strongly recommend following the current
immunization schedule established by the ACIP (Advisory Committee on Immunization Practices)
and adopted as standard of care by the CDC (Center for Disease Control) and AAP (American Academy
of Pediatrics). The current national guidelines have been shown to be both safe and effective in
preventing disease. However, our providers also understand and acknowledge parental concerns
regarding the safety of immunizations. When parents choose to not follow the current immunization
guidelines, the providers at High Desert Pediatrics will try their best to work with the parents so that
they are comfortable with the care that is received. However, any deviation from the immunization
schedule is not endorsed by our healthcare providers and should not be considered a
recommendation of an alternative immunization schedule.
• The risks of not following the nationally recommended immunization schedule include
an increased risk of infection for the child as well as for others with whom that child
may come in contact.
• Other consequences may also include the inability to enroll in daycare*, school*,
military, or organized activities due to lack of immunizations.
• The decision to use an alternate immunization schedule or to not immunize for reasons
other than established medical diagnoses is the sole responsibility of the parents.
I acknowledge that I have read this document and fully understand it.
Parent/Guardian Signature: ______________________________________________________________________________
Today’s Date: ________________________
*Information on New Mexico School and Daycare Immunization Requirements may be found at
http://www.immunizenm.org/sched.shtml. Please note that NM “law does not grant immunization exemptions
for philosophical or personal reasons.”
7 | P a g e
8650 Alameda Blvd NE
Suite 101E
Albuquerque, NM 87122
T (505) 255-1866
F (505) 255-1852
HIPAA Notice of Privacy Practices
Your Medical Record: Each time you visit a hospital or physician, a record is made of your visit.
This information, commonly known as a medical record, contains your symptoms, examination and
test results, diagnosis, and a plan for future care. The confidentiality of your medical record is
protected under the State-specific and Federal Law.
Your Health Information Rights: Your medical record is the physical property of the physician or
healthcare facility that compiled it, but the information belongs to you. Therefore, you have rights
regarding the use and disclosure of your health information.
Our Responsibilities: High Desert Pediatrics is required by the Federal Privacy Rule to maintain
the privacy of your medical record and to provide you with notice of our legal duties and privacy
practices.
Uses and Disclosures for Treatment, Payment, and Health Care Operations:
Treatment: Means the provision, coordination, or management of healthcare and related services
by one or more health care providers. We will provide other providers or hospitals with copies of
your medical record to assist them in treating you, should that become necessary.
Payment: Payment means the activities undertaken by a health care provider or health plan
to obtain or provide reimbursement for the provision of health care. The information on a bill
may include information that identifies you, as well as your diagnosis, procedures, and supplies
used.
Health Care Operations: Health care operations means conducting quality assessment and
improvement activities, reviewing the competence or qualifications of health care professionals,
underwriting, premium rating, and other activities related to health insurance contracts. This also
included medical reviews, legal services, auditing functions, business management, and general
administrative activities of the practice.
High Desert Pediatrics will disclose your health information to business associates, such as a
medical transcription or billing service so that they can perform the job we have asked them to do.
Disclosures Permitted Without Consent: High Desert Pediatrics is required by State and Federal
law to disclose health information from your medical record under specific circumstances.
• U.S. Department of Health and Human Services: High Desert Pediatrics must disclose your
medical information upon request for purposes of determining whether we follow Federal
Privacy Laws. We may disclose your medical information to a Government Agency authorized
to oversee the Health Care system or Government programs or its contractors, and to Public
Health authorities for Public Health purposes.
• Law Enforcement: High Desert Pediatrics may disclose your medical information in response
to a court or administrative order, subpoena, discovery request, or other lawful process, under
certain circumstances. Under limited circumstances, such as a court order, warrant, or grand
jury subpoena, we may disclose your medical information to law enforcement officials.
8 | P a g e
8650 Alameda Blvd NE
Suite 101E
Albuquerque, NM 87122
T (505) 255-1866
F (505) 255-1852
• Abuse or Neglect: High Desert Pediatrics may disclose your medical information to appropriate
authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic
violence, or the possible victim of other crimes. We may disclose your medical information to
the extent necessary to avert a serious threat to your health or safety or the health or safety of
others.
Uses and Disclosures Specifically Authorized by You: High Desert Pediatrics will use and
disclose your health information only based on specific written authorization forms signed by
you. If you give us a written authorization, you may revoke it in writing at any time.
• To Your Family and Friends: We cannot use or disclose your medical information for
any reason except that described in the notice. We may disclose your medical information
to a family member, friend, or other person to the extent necessary to help with your
health care or with payment for your health care, but only if you agree that we may do so.
• Persons Involved in Your Care: We may use or disclose medical information to notify
or assist in the notification of (including identifying or locating) a family member, your
personal representative, or another person responsible for your care, your location, your
general condition, or death. If you are present, then prior to use or disclosure of your
medical information, we will provide you with an opportunity to object. In the event of
your incapacity or emergency circumstances, we will disclose protected health
information based on a determination using our professional judgment disclosing only
protected health information that is directly relevant to the person’s involvement in your
health care. We will also use our professional judgment and our experience with common
practice to make reasonable inferences of your best interest in allowing a person to pick
up prescriptions, medical supplies, or other similar forms of medical information.
• Individual Rights: You have the right to look at or get copies of your medical information,
with limited exceptions. You may request that we provide copies in a format other than
photocopies. We will use the format you request unless we cannot do so. You must make
a request in writing to obtain access to your medical information. We may charge a
reasonable fee to produce copies of your personal health information. The fee is $30 for
the first 15 pages and then $0.25 for each additional page.
To Report a Problem: If you are concerned that we may have violated your privacy rights or
you disagree with a decision we made about access to your medical information or in response
to a request you made to amend or restrict the use or disclosure of your medical information or
to have us communicate with you by alternative means you may do so directly with High Desert
Pediatrics or with the Secretary of Health and Human Services in Washington, D.C.
9 | P a g e
8650 Alameda Blvd NE
Suite 101E
Albuquerque, NM 87122
T (505) 255-1866
F (505) 255-1852
Acknowledgement of HIPAA Notice of Privacy Practices
High Desert Pediatrics will use and disclose your personal health information to treat you, to
receive payment for the care we provide, and for other health care operations. Health care
operations generally include those activities we perform to improve the quality of care.
We have prepared a detailed HIPAA Notice of Privacy Practices to help you better understand our
policies regarding your personal health information. The terms of the notice may change with
time, and we will always post the current notice at our office and have copies available for
distribution.
• I acknowledge that I have received a copy of the HIPAA Notice of Privacy Practices.
• I consent to allowing High Desert Pediatrics to disclose my protected health information
for treatment activities of another health care provider.
• I consent to allowing High Desert Pediatrics to disclose my protected health information
to insurance companies to facilitate claims processing.
• I consent to allowing High Desert Pediatrics to disclose protected health information to
another medical facility for health care operation activities provided that the practice and
the other entity has or had a relationship with the below named patient. The disclosure
must be for treatment, payment, or health care operations for the purpose of health care
fraud and abuse detection or compliance.
Patient Name: ________________________________________________________________________________________________
(Please Print Patient Name)
____________________________________________________________________________________________________
(Signature of Person Authorizing Consent)
______________________________________ / ____________________________________________________________
(Print Name of Person Authorizing Consent / List Relationship to Patient)
Today’s Date: _____________________
10 | P a g e
8650 Alameda Blvd NE
Suite 101E
Albuquerque, NM 87122
T (505) 255-1866
F (505) 255-1852
Release of Medical Record Authorization
Date of Request: ________________________________ Date Needed: ________________________________
Name: ___________________________________________________________________________ Date of Birth: ______ /______ /_______
Address: __________________________________________________________________________________________________________________
City: _____________________________________________________________________ State: ___________ Zip Code: _________________
SSN: __________________________________________________________________ Phone #: ________________________________________
I authorize my medical health information be: ☐ Obtained From ☐ Released To
Name of Provider/Facility: ____________________________________________________________________________________________
Address: _____________________________________________________________ City/State/Zip: ________________________________
Phone #: (_______)_____________________________________ Fax #: (_______)______________________________________
PURPOSE FOR THIS REQUEST: ☐ Transfer of Care ☐ Healthcare ☐ Insurance ☐ Legal
☐ Personal ☐ Other: ______________________________________
TYPE OF RECORDS REQUESTED: SPECIFY ILLNESS/INJURY: _____________________________________________________
TREATMENT PERIOD: From: (Month/Year) ___________________________ To: (Month/Year) ______________________
CHECK ALL THAT APPLY:
☐ All Records ☐ History/Physical ☐ Lab Results ☐ Vaccine Records ☐ Any Radiology
☐ Procedure Report ☐ Medication List ☐ Other: _____________________________________________________________
AUTHORIZATION VALID FOR: ☐ This request only ☐ One year from the date of this authorization
I understand that:
• My right to healthcare is not conditioned on this authorization.
• I may cancel this authorization at any time by submitting a written request to the address provided at the top of this form, except where a
disclosure has already been made in reliance on my prior authorization.
• If the person/facility receiving this information is not a healthcare or insurance provider covered by privacy regulations, the information stated
above could be redisclosed.
• Release of HIV-related information, mental health related care, or substance abuse diagnosis and treatment information requires additional
authorization.
• There may be a charge for the requested records.
NOTE: Medical Records are faxed in cases of medical necessity
Signature of Patient or Parent/Guardian: __________________________________________________________________________
Relationship to Patient: ______________________________________________________________ Date: ________________________
11 | P a g e
8650 Alameda Blvd NE
Suite 101E
Albuquerque, NM 87122
T (505) 255-1866
F (505) 255-1852
Telehealth Consent
Patient Name: __________________________________________________________________________ DOB: ________________________
Parent/Guardian Full Name: __________________________________________________________________________________________
Overview
• To receive telehealth services from High Desert Pediatrics you must have access to the technological
tools that are needed to engage in the telehealth services (i.e. Smartphone device with front facing
camera or computer with a webcam and a reliable internet connection).
• You will need to have a designated room/area in which you are able to give your full attention and
participation during the telehealth visit. They are to be treated as if it is an in-office visit.
Confidentiality
Electronic systems used will incorporate network and software security protocols to protect the
confidentiality of patient identifiers and imaging data and will include measures to safeguard the data and
ensure its integrity against intentional or unintentional corruption. Reasonable and appropriate efforts have
been made to eliminate any confidentiality risks associated with the Telehealth visit.
Quality of Communication for Telehealth Visits
By using the telehealth service, I recognize that any transmissions over the internet are at my own risk and
that third parties may unlawfully intercept or access the transmissions being sent. I also understand that
despite all reasonable efforts on the part of the provider, there are risks and consequences in using telehealth
services. The risks include, but are not limited to, the possibilities that the transmission of sessions could be
disrupted or distorted by technical failures. In the case of technical failures, the provider will make every
effort to reconnect with me through electronic means, as will I. I also understand that telehealth services may
not be completely thorough as services provided via face-to-face, although there are several benefits of
telehealth services that have been identified. One which includes increased access to specialized services in
remote areas, lower healthcare costs, reduced travel time, minimizing time off work, decreased waiting times,
and social distancing.
I have been notified by High Desert Pediatrics that if my provider believes the patient would be better served
by a face-to-face visit, I will be asked to call the office to schedule an in-office appointment. I understand that
the telehealth service will be billed through my insurance (if applicable) and I will be responsible for any
charges that are not covered by my insurance plan (if applicable). I also understand the services I receive will
be considered an office visit and my encounter notes will be kept on file at High Desert Pediatrics in the same
fashion as a standard clinic visit.
I understand that if I do not contact High Desert Pediatrics to cancel or reschedule my scheduled appointment
the visit will be considered a No Call/No Show.
☐ I consent to Telehealth services ☐ I DO NOT consent to Telehealth services
Today’s Date: _____________________________
