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    TULLAHOMA PEDIATRICS, PLLCPATIENT INFORMATION SHEET

    Patient Full Legal Name:_________________________________ Nickname:__________________ Birthdate:____________

    Patient Address:________________________________ City:_______________ State:____________ Zip:______________

    Patient Home Phone:______________________ Patient SSN:__________________ Sex: Male ________ Female________

    Emergency Contact(Not parents or guardians): _____________________ Relationship to patient__________ Phone #__________

    Insurance Information

    Insurance #1 Insurance #2

    Name of Insurance:_____________________________ Name of Insurance:______________________________

    Person who is insured:___________________________ Person who is insured:___________________________

    Relationship to pateint:__________________________ Relationship to pateint:___________________________

    DOB of insured:________________________________ DOB of insured:________________________________

    SSN of insured:________________________________ SSN of insured:________________________________

    I HAVE NO OTHER INSURANCE THEN THAT LISTED ABOVE___________(initials)____________(date)

    Parent/Legal Guardian Information

    Mother's Father's Legal Guardian's

    Name:__________________________ Name:__________________________ Name:__________________________

    Address:________________________ Address:________________________ Address:________________________

    City:________ State:_____ Zip:______ City:________ State:_____ Zip:______ City:________ State:_____ Zip:______

    Phone#:_________________________ Phone#:_________________________ Phone#:_________________________

    DOB:___________________________ DOB:___________________________ DOB:___________________________

    SSN:____________________________ SSN:____________________________ SSN:____________________________

    Employer:________________________ Employer:________________________ Employer:________________________

    Employer phone:___________________ Employer phone:___________________ Employer phone:___________________

    Email:___________________________ Email:________________________ Email:___________________________

    Foster Parent's/Step-Parent's As a security measure, and in compliance with the federal HIPPA regulations, we will

    Name:__________________________ assign your child a four-digit PIN number. Please keep this number in a secure place

    Address:________________________ because each time your child comes to our office we will ask you for the PIN number

    City:________ State:_____ Zip:______ and your child's insurance card. If you are unable to bring your child in for his/her

    Phone#:_________________________ appointment, and you ask someone else to accompany the child, you will need to give

    DOB:_________SSN:_______________ that person your child's PIN number and insurance card.

    Case Worker's Name________________ I understand I am giving permission for another person to make medical decisions and

    County:_________________________ obtain medical information for my child when I give them my child's PIN #____initials

    Case Worker's phone:_______________ I understand by providing my child's PIN number I will be able to obtain medical

    Case Worker's Fax #:________________ information over the phone and in the office._____initials

    Email:___________________________

    RELEASE AND ASSIGNMENT

    I authorize release of any medical information or other information necessary to process my insurance claims. I assign and request payment directly

    to my physicians.I understand that some services may not be covered by insurance. I accept full financial responsibility and agree to pay the full amount

    due or the remainder not paid by insurance. I understand that I am responsible to pay for services rendered, including reasonable attorney's fees

    and costs of collection in the event of default. I understand that I am responsible to provide a current copy of my insurance card each time

    my child is seen to assure correct billing. I understand that if I don't provide the correct insurance information I am responsible

    for the full amount due.

    I understand that I am responsible for providing this office with any updated information.

    I understand that I am required to complete and sign a patient information sheet yearly.

    Date:____________________ X Signature:______________________________________________________________________________________

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    Tullahoma Pediatrics PLLC Patient Consent Form

    The Department of Health and Human Services has established a Privacy Rule to help insure that personalhealth care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for

    certain health care provider to obtain their patients consent for uses and disclosures of health information about patientsto carry out treatment, payment, or health care operations.

    As our patient we want you to know that we respect the privacy of your personal medical records and will do all

    we can to secure and protect that privacy. When it is appropriate and necessary, we provide the minimum necessary

    information to only those we feel are in need of our health care information and information about treatment, payment or

    health care operations, in order to provide health care that is in your best interest.

    We also want you to know that we support your full access to your personal medicals records. We may have

    indirect treatment relationships with (such as laboratories that only interact with physicians and not patients), and may

    have to disclose personal health information for the purposes of treatment, payment, or health care operations. These

    entities are most often not required to obtain patient consent.

    You may refuse to consent to the use or disclosure of your personal health information, but this must be in

    writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal

    Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse

    all or part of your PHI, You may not revoke actions that have already been taken which relief on this or a previously

    signed consent.

    If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer.

    You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you

    have reviewed our privacy notice.

    I have reviewed this privacy notice and have obtained a copy of the compliance assurance notification. At this time I have

    no questions for the HIPAA Compliance Officer.

    _________________________ _________________________ _______________

    Print Patients Name Signature Parent or Guardian Date

    _________________________ _______________

    Witness Signature Date

    COMPLIANCE ASSURANCE NOTIFICATION FOR OUR PATIENTS

    To Our Valued Patient and Family Members:

    The Misuse of Personal Health Information (PHI) has been identified as a national problem causing patients

    inconvenience, aggravation, and money. We want you to know that all of our employees, manager and doctors

    continually undergo training so that they may understand and comply with government rules and regulations regarding the

    Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the Privacy Rule. We strive

    to achieve the very highest standards of ethics and integrity in performing services for our patients.It is our policy to properly determine appropriate uses of PHI in accordance with the governmental rules, laws and

    regulations. We want to ensure that our practice never contributes in any way to the growing problem of improperdisclosure of PHI. As part of this plan we have implemented a Compliance Program that we believe with help us prevent

    any inappropriate use of PHI.

    We also know that we are not perfect? Because of this fact, our policy is to listen to our employees and our

    patients without any though of penalization if they feel that an event in any way compromises our policy of integrity.More so, we welcome your input regarding any service problem so that we may remedy the situation promptly.

    Thank you for being one of our highly valued patients and family members.

    Tullahoma Pediatrics PLLC

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    Tullahoma Pediatrics PLLC

    RESPONSIBLE PARTY STATEMENT

    DEFINITION: The Responsible Party is the person(s) who present and/or authorize the patient to Tullahoma

    Pediatrics for treatment and completes this form.

    Responsible Party Authorizes:

    --Tullahoma Pediatrics to furnish information to insurance carriers concerning patients illness and

    treatments.

    RESPONSIBILITIES:

    --ALL CHARGES are due at the time services are rendered unless patient is a member of an insurance

    plan with which Tullahoma/Manchester Pediatrics participates. Tullahoma Pediatrics only allows contractual

    adjustments for plans with which our physicians currently have a contract.

    --If patient is covered by a plan with which Tullahoma Pediatrics participates the following will apply:

    --COPAYS are due at the time of service unless the copay is a percentage of allowable charges.

    In this case copay will be due immediately after insurance has processed claim with a dollar amount as copay.

    --ALL CHARGES deemed patient responsibility after insurance has processed the claim are due

    immediately. This includes copays, deductibles, coinsurance and non-covered services.

    --Financially responsible for all charges whether or not covered by insurance.

    --A valid patients insurance card must be presented at each and every visit.

    --Tullahoma Pediatrics must be notified immediately of coverage changes. Failure to provide us with

    timely insurance information or change in coverage could result in the responsible party being held liable for the

    total charges.

    --Any services filed with your insurance that are not responded to any time after 90 days from the date

    of service may be transferred to patient balance and will become the responsibility of the family.

    RIGHTS:--Tullahoma Pediatrics will file claims promptly for patients who participate with contracted insurance

    plans.

    --A copy of charge/payment history for account as requested.

    --A copy of this statement may be given upon request to the person(s) who have signed or who have

    been authorized by the Responsible Party to receive a copy.

    --This statement will be valid unless rescinded in writing by one at a later date.

    ______ I have received a copy of Tullahoma Pediatrics Financial Policy which further outlines my rights and

    responsibilities.

    By my signature I understand and agree to the conditions outlined in this statement and those in the Financial

    Policy.

    __________________________________ ____________________________________

    Printed Name Signature

    DATE: ____________________________ _________________, Staff Initials

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    TULLAHOMA PEDIATRICS PLLC

    THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU OR YOUR CHILD (children) MAY BE USED

    AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

    Tullahoma Pediatrics PLLC, including staff, physicians, and other health care providers on our staff, use and share health information

    about you or your child (children) for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate thequality of care that you receive. We are committed to protecting health information about you or your child (children). Your or your

    childs health information is contained in a medical record that is the physical property of Tullahoma Pediatrics PLLC.

    HOW WE MAY USE YOUR HEALTH INFORMATION:

    FOR TREATMENT. We may use your or your childs health information to provide, coordinator or manage medical treatment or

    related services. Information obtained by a nurse, physician, or other member of the healthcare team will be recorded in the medical

    record and used to determine the course of treatment that will work best for you or your child.

    FOR PAYMENT. We may use and disclose health information to bill and collect payment for treatment and services that are

    received. For example, a bill may be sent to you or to your insurance company. The bill will contain information that identifies you or

    your child (children), as well as the diagnosis, procedures and supplies used in the course of treatment.

    FOR HEALTH CARE OPERATIONS. We may use and disclose health information about you or your child (children) for office

    operations. For example, you or your childs health information may be disclosed to other staff members to :

    To evaluate the performance of our staff Assess the quality of care Learn how to improve our facilities and services; and Determine how we can make improvements in the care and services we provide

    APPOINTMENTS/RETURN VISITS. We may use your or your childs information to contact you as a reminder that you have an

    appointment for treatment or to follow-up regarding medical care.

    INDIVIDUALS INVOLVED IN YOUR CARE. We may share information with a family member or other person identified by you

    or who is involved in your or your childs care or payment related to that care. We may tell a family member or friend about you or

    your childs condition. If you do not want that information released to those involved in the care, see instructions for requ esting a

    restriction under YOUR HEALTH INFORMATION RIGHTS.

    HOW WE MAY DISCLOSE YOUR OR YOUR CHILD (CHILDRENS) HEALTH INFORMATION OUTSIDE OF

    TULLAHOMA PEDIATRICS PLLC:

    REQUIRED BY LAW/PUBLIC HEALTH. We may disclose information about you or your child (children) when required to do so

    by federal, state or local laws. For example, we may disclose information for the following purposes:

    To respond to a court order, subpoena or deposition. To assist law enforcement officials in their duties to locate a suspect, fugitive or missing person. To report information related to victims of child abuse or neglect. To report reactions to medication or recalls of products. To federal and state agencies for oversight activities authorized by law such as investigation, inspections, audits, surveys

    and licensing. (Examples may include organizations that ensure the quality/safety of the care we provide).

    HEALTH RISKS. You or your childs health information may be released for public health activities such as assisting public health

    authorities or other legal authorities to prevent or control disease, injury, or disability. We may disclose your or your childs health

    information to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease.

    HEALTH AND SAFETY. We may disclose health information about you or your child (children) to avert a serious threat to the

    health or safety of you, any other person or the public. Any disclosure would only be to someone able to help prevent the threat.

    DECEASED. Health information may be disclosed to funeral directors, medical examiners or coroners to enable them to carry out

    their lawful duties.

    ORGAN/TISSUE DONATION. If you or your child (children) are an organ donor, we may release health information to

    organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank.

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    RESEARCH. We may disclose information for research purposes when Tullahoma Pediatrics PLLC has reviewed and approved the

    research proposal. Medical record information that identifies you or your child (children) will only be used when given permission for

    us to do so. Additionally, when given permission, we may contact you regarding research purposes.

    NATIONAL SECURITY. We may disclose your or your childs health information to federal officials for intelligence,

    counterintelligence, and national security activities authorized by law.

    TREATMENT ALTERNATIVES. We may use and disclose health information to tell you about or recommend possible treatment

    options or other health-related benefits and services that may be of interest to you.

    WORKERS COMPENSATION. Your or your childs health information may be used or disclosed in order to comply with laws and

    regulations related to Workers Compensation or similar programs. These programs provide benefits for work-related injuries or

    illness.

    YOUR HEALTH INFORMATION RIGHTS

    In accordance with federal regulations and Tullahoma Pediatrics policies and procedures, you have the right to:

    Request a restriction on certain uses and disclosures of your or your childs health information. We will make everyeffort to honor your request. However, in some situations, we may be required by law to share the health information. As

    an example, tuberculosis (TB)_ results are required by law to be reported to the Health Department. Tullahoma

    Pediatrics are not required to agree to all requested restrictions.

    Request to inspect and/or obtain a copy of your or your childs health record. You have the right to request to inspectand/or obtain a copy of the health information and billing records. We may charge a fee for the costs associated with

    copying and/or mailing the information.

    Request to correct/amend information in your or your childs health record . If you fell that health information we have isincorrect or incomplete, you may ask us to correct/amend the information. If the health information is determined to be

    incorrect or incomplete, we will revise the record.

    Request confidential communications. You have the right to request that we communicate with you about healthinformation in a particular manner or at a location other than your permanent address. For example, you may ask that we

    contact you by mail rather than by telephone, or at work rather than at home. It is your responsibility to make sure that

    we have your correct address and contact information.

    Receive a listing of how your or your childs information has been shared. You have the right to receive a listing ofdisclosures of the health information for purposes outside of treatment, payment or office operations.

    Receive a paper copy of this notice. You have the right to a paper copy of this notice. You may ask us to give you a copyof the notice at any time.

    In order to request a restriction on how your or your childs health information is used or to request confidential c ommunication, you

    must complete a Restriction of Health Information Request Form. In order to request a copy, an inspection, a correction/ame ndment

    or a listing of disclosures you must submit a request in writing to the Medical Records Department.

    OBLIGATIONS OF TULLAHOMA PEDIATRICS PLLC

    We are committed to:

    Make sure that medical information that identifies you, your child (children) is kept private. Provide you with this notice of our legal duties and privacy practices with respect to you or your childs health

    information.

    Follow the terms of this notice. Notify you, after managements review, if we are unable to agree to a requested restriction on how health information is

    used or disclosed.

    Accommodate reasonable requests for communications of health information in a particular manner or to a location otherthan your permanent address.

    Obtain your written authorization to disclose health information for reasons other than those listed above and permitted.Tullahoma Pediatrics reserves the right to change the terms of this notice and to make the new provisions effective for all

    protected health information it maintains. Revised notices will be made available to you by posting them ion our office,

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    posting them on our website atwww.tullahomapediatrics.comand upon your request, we will provide you with a copy of

    the most recent copy of our Notice of Privacy Practices.

    CONTACT INFORMATION

    You may file a complaint to Tullahoma Pediatrics or to the United States Secretary of the Department of Health and Human Services

    if you believe you or your childs privacy rights have been violated. You will not be penalized for filing a complaint.

    http://www.tullahomapediatrics.com/http://www.tullahomapediatrics.com/http://www.tullahomapediatrics.com/http://www.tullahomapediatrics.com/
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    Tullahoma Pediatrics PLLC

    FINANCIAL POLICY

    Welcome to Tullahoma! Were glad youve chosen us as your childs pediatricians and we strive to give

    your children the best in medical care. We understand that in addition to needing to feel comfortable with

    your childs physician, many parents have concerns about the financial policies of the practice. Thisinformation is designed to answer frequently asked questions.

    CONTRACTED INSURANCE FILING:

    We currently have contracts with the following insurance companies/plans:

    Blue Cross Blue Shield Principal Great West

    Cigna FMH Benefit Services Covenant

    Aetna Signature Health Alliance Aerospace

    United Healthcare Benefit Planners GEHA

    We do take most private insurances. If you do not see your insurance company listed please call ourbilling department to verify coverage.

    Americhoice TennCare Select

    Blue Care We do NOT participate in PHP, Tri Care or Amerigroup

    Tullahoma /Manchester Pediatrics company policies regarding our participation with these contracted

    plans are as follows:

    1. Tullahoma Pediatrics has agreed to file insurance claims for patients who participate in theseplans. In order to do this as accurately as possible, we MUST see your childs insurance card at

    each visit; and if you participate with a managed care program, one of our physicians names

    must appear on the card.

    2. IF YOU DO NOT HAVE YOUR CHILDS INSURANCE CARD AT EACH VISIT ORANOTHER PHYSICIANS NAME APPEARS ON THE CARD, YOU MAY BE ASKED TO

    SIGN A WAIVER AND LEAVE PAYMENT AT THE TIME OF VISIT.

    3. We will, in some cases, accept a paper copy of online eligibility at Check-In as long as itincludes: patients name, proof of eligibility for medical services on the date of service, and

    online address of contracted insurer.

    4. We collect all co-payments at the time services are rendered and file insurance on a daily basis.5. Any services that are deemed to be the familys responsibility (additional co-pays, coinsurance,

    deductible, etc.) or that are considered non-covered by your insurance will be put to patient

    balance and are due immediately.6. Any services that we file with your insurance that are not responded to after 90 days from the date

    of service may be transferred to patient balance. This balance will remain the responsibility of the

    family until payment is received or written correspondence is received by the insurance company

    verifying that payment is forthcoming from them.

    7. A monthly statement will be sent to you detailing unpaid charges. If you have questionsregarding items which have not been paid by your insurance, we ask that you contact your

    insurance company or employer as benefit packages vary by employer.

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    NON-CONTRACTED INSURANCE OR SELF PAY:

    If we do not participate with your insurance plan, we ask that you pay in full at the time services are

    rendered. We will provide you with a form suitable for filing with your insurance company. You

    need only to fill out our portion of the insurance claim form, attach our encounter form and mail to

    your insurance company.

    SEPARATED/DIVORCED FAMILIES:

    1. For those families where parents are separated or divorced, the parent authorizing treatment and

    bringing the child to be seen is responsible to us for payment.. All payments are due when

    when services are rendered.

    2. In the case of contracted insurance only, copay is due at the time services are rendered.

    Subsequently all charges deemed parent responsibility by the contracted insurer are due to

    Tullahoma/Manchester Pediatrics by the parent who authorized treatment.

    3. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the

    authorizing parents responsibility to collect from the other parent. Tullahoma Pediatrics will not

    act as a mediator in collecting our payments.

    4. A copy of the bill with appropriate insurance coding will be given to the authorizing parent upon

    request.

    5. If the account is not resolved in a timely manner, the authorizing parents information will be

    submitted to our collection agency.

    6. Non-compliance with this policy may result in transfer of care to another practice.

    PRACTICE CLOSINGS:

    Tullahoma Pediatrics is closed to the following populations: PHP & TriCare/Champusand Amerigroup .

    *A patient is established only if they have been seen by one of our physicians in the last 3 years.

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    Physicians and staff at Tullahoma Pediatrics PLLC congratulate you on the birth of your

    baby. We are pleased that you have chosen us to care for your childs medical needs. As

    your childs pediatrician we are dedicated to assist you in rearing your child by providingthe best possible medical care. We also want to be sure that moms needs are met during

    these first few weeks. With that goal in mind we would like your permission to share

    information obtained from you with your OB/GYN.

    OB/GYN Name: _________________________________________________

    OB/GYN Address: _______________________________________________

    OB/GYN Telephone: _____________________________________________

    Yes, I give my consent for Tullahoma Pediatrics PLLC to

    share Post Partum Test results with the OB/GYN listed above.

    No, I do not give my consent for Tullahoma Pediatrics PLLC to share Post Partum Test results with my OB/GYN.

    ____________________________ ____________________________ __________

    Please Print Your Name Print your childs name and date of birth

    ______________________________________________

    Signature

    ______________________________________________

    Date

    11/07

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    Edinburgh Postnatal Depression Scale (EPDS)

    Patients Name: _________________________________________________

    Your Name: ____________________________________________________

    Date: ________________________ Babys Age: _______________________

    As you have recently had a baby, we would like to know how you are feeling. Please mark theanswer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feeltoday. Here is an example, already completed.

    I have felt happy:

    ___ Yes, all the time This would mean: I have felt happy most of the time Yes, most of the time during the past week. Please complete the___ No, not very often other questions in the same way.

    ___ Not at all

    1. I have been able to laugh and see the funny side of things. _____

    ___ As much as I always could___ Not quite so much now___ Definitely not so much now___ Not at all

    2. I have looked forward with enjoyment to things. _____

    ___ As much as I ever did___ Rather less than I used to___ Definitely less than I used to___ Hardly at all

    3. *I have blamed myself unnecessarily when things went wrong _____

    ___ Yes, most of the time___ Yes, some of the time___ Not very often

    ___ No, never

    4. I have been anxious or worried for no good reason. _____

    ___ No, not at all___ Hardly ever___ Yes, sometimes___ Yes, very often

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    5. *I have felt scared or panicky for not very good reason. _____

    ___ Yes, quite a lot

    ___ Yes, sometimes___ No, Not much___ No, at all

    6. *Things have been getting on top of me. _____

    ___ Yes, most of the time I havent been able to cope at all ___ Yes, sometimes I havent been coping as well as usual ___ No, most of the time I have coped quite well___ No, I have been coping as well as ever

    7. *I have been so unhappy that I have had difficulty sleeping. _____

    ___ Yes, most of the time___ Yes, sometimes___ Not very often___ No, not at all

    8. *I have felt sad or miserable. _____

    ___ Yes, most of the time___ Yes, quite often___ Not very often___ No, not at all

    9. *I have been so unhappy that I have been crying. _____

    ___ Yes, most of the time___ Yes, quite often___ Only occasionally___ No, never

    10. *The thought of harming myself has occurred to me. _____

    ___ Yes, quite often___ Sometimes___ Hardly ever___ Never

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    SYN07-111

    PARENT QUESTIONNAIRE

    In an effort to help our office better serve families with children under two years of

    age, please complete this questionnaire to see if your child is at high risk for

    developing a severe RSV (respiratory syncytial virus) infection.

    CHILDS NAME: ______________________________

    DATE OF BIRTH: ____________________________________

    1. Was your child born more than 4 weeks early (prematurely)? Yes (How many weeks?) No

    2. Was your child in the neonatal intensive care unit (NICU) after birth? Yes (How many days?) No

    3. Has your child ever been re-hospitalized? Yes (If yes, please explain) No

    4. Has your child ever had any respiratory or breathing difficulties? Yes (If yes, please explain) No

    5.

    Does your child have a heart or lung condition? Yes (If yes, please explain) No

    6. Does your child have an immune deficiency? Yes (If yes, please explain) No

    7. Please check any of the situations listed below that may pertain to your child. My child is around other children for more than 4 hours per week. My child attends daycare, either in the home, a center, gym or place of worship. My child lives with siblings or other children. My child is exposed to tobacco smoke, wood burning stoves or kerosene heaters. My child lives more than 30 miles from the nearest hospital.

    Signature: _______________________________ Date: _______________________

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    2005 MedImmune, Inc. SSP05-175

    RSV PROPHYLAXIS ASSESSMENT*

    PATIENTS NAME: _______________________________________________DATE: ____________________

    DATE OF BIRTH: _____________GESTATIONAL AGE (GA): ________wks BIRTH WEIGHT: ___________(kg)

    REGIONAL RSV SEASON START DATE: October OTHER INFO: ________________________________

    1. Will the patient be less than 2 years of age at thestart of the season ?

    Yes

    Proceed to Question #2

    No

    Not Eligible

    2. Does patient have Chronic Lung Disease (CLD/BPD),hemodynamically significant Congenital Heart Disease(CHD), or other serious condition that compromisespulmonary or immune function (other than prematurity)?

    YesConsider Prophylaxis

    NoProceed to

    Question #3

    3. Was the patient born prematurely (

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    ON THE BIRTH OF YOUR BABY

    TO CONTINUE TO RECEIVE INSURANCE BENEFITS YOU MUST CONTACT

    YOUR INSURANCE CARRIER BEFORE THE INFANT IS

    30 DAYS OLD TO LET THEM KNOW:

    1. THE BABY HAS BEEN BORN2. WHICH PROVIDER YOU WANT ON THE CARD:

    CLIFFORD A. SEYLER, MD, FAAP JENNIFER GOODWIN, FNPC

    THE NUMBER YOU WILL CONTACT IS THE CUSTOMER SERVICE NUMBER

    LISTED ON YOUR CURRENT INSURANCE CARD.

    BCBS

    1-800-565-9140

    IF YOU HAVE TENNCARE THE BABY IS ONLY COVERED FOR 30 DAYS .

    IF YOU DO NOT CALL AND LET THEM KNOW WHICH DOCTOR TO PUT ON

    THE CARD THEY WILL PUT A DOCTOR ON THE CARD FOR YOU.

    TENNCARE NUMBERS

    AMERICHOICE 1-800-690-1606 TENNCARE SOLUTIONS 1-800-878-3192

    TENNCARE SELECT 1-800-263-5479 BLUECARE 1-800-468-9698