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					                                     Regina A. George, M.D.
                                    54 Scott Adam Road, #105
                                     Cockeysville, MD 21030
                              410-666-2020 Phone / 410-666-3257 Fax

Welcome to our Practice!

For our New Patients:
Please complete the attached forms and return them to us PRIOR to your first appointment. Please
arrive 15 min prior to your appointed time for you first visit.

For Those Transferring to Us:
We also request records from your previous pediatrician. PLEASE DO THIS PRIOR TO YOUR
FIRST APPOINTMENT. We will NOT schedule your child until we have all records and completed

Most importantly, we need a copy of your child’s immunization record. We would also like a copy
of the last physical examination, a copy of your child’s growth chart, and any pertinent lab work
(such as the blood lead level tests) or reports from any specialists your child may have seen. We do
NOT need every page of your child’s previous chart.

Please notify your insurance company that you have chosen Dr. George as your child’s new
pediatrician. If a physician’s name appears on your insurance card, it MUST say DR. GEORGE’S
name before we can see your child. We will NOT accept an insurance card that bears the name of
another physician. We will make a copy of your insurance card and drivers license at your first

                       CO-PAYS ARE DUE AT THE TIME OF SERVICE!

                                WE ACCEPT CASH OR CHECK.


                              Thank you and welcome to our practice!
                                       Regina A. George, M.D.
                                      54 Scott Adam Road, #105
                                       Cockeysville, MD 21030
                                410-666-2020 Phone / 410-666-3257 Fax

                                        Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed, and how you can
get access to this information. Please review it carefully.

We are required by law to maintain the privacy of your medical information and to provide you with
notice of our legal duties and privacy practices followed by our staff. The practices described in this
notice will also be followed by healthcare providers you consult with by telephone (when Regina A.
George is not available) who provide “call coverage” for Regina A. George.

We may use and disclose your medical records only for each of the following purposes: treatment,
payment, and health care operations.

Treatment means providing, coordination, or managing health care and related services by one or more
health care providers. An example of this would include a physical examination.

Payment means such activities as obtaining reimbursement for services, confirming coverage, billing,
and utilization review. An example of this would be sending a bill for your visit to your insurance
company for payment.

Health Care Operations include the business aspects of running our practice, such as reviewing past
records or billing information for compliance by external auditors. An example would be review by an
Insurance Company Case Manager to confirm immunizations are up to date.

Disclosure without Authorization:
We may use and disclose medical information about you, without your specific authorization.

Disclosure Required By Law:
We may be required by Federal, State, or local law to disclose your medical information.

Public Health Activities:
We may disclose you medical information to a public health agency, in order to prevent or control disease,
injury, suspected abuse or neglect, reactions to medications or problems with products.

Judicial & Administrative Proceedings:
We may have to disclose you medical information if we receive a court subpoena or administrative order.

We may also create and distribute de-identified health information by removing all references to
individually identifiable information.

Any other disclosures will be made only with your written authorization. You may revoke such
authorization in writing and we are required to honor and abide by that written request, except to the
extent that we have already taken actions relying on your authorization.
You have the following rights with respect to your protected health information, which you can exercise
by presenting us with a written request:

*The right to request restrictions on certain uses and disclosures of protected health information,
including those related to disclosures to family members, or other relatives, close personal friends, or any
other person identified by you. We are, however, not required to agree to a requested restriction. If we do
agree to a restriction, we must abide by it unless you agree in writing to remove it.

*The right to reasonable requests to receive confidential communications of protected health information
from us by alternative means or at alternative locations.

*The right to inspect and copy your protected health information.

*The right to amend your protected health information.

*The right to receive an accounting of disclosures of protected health information.

*You are entitled to receive a paper copy of your Notice of Privacy Practices.

This Notice is effective as of June, 10, 2002, and we are required to abide by the terms of the Notice of
Privacy Practices currently in effect. We reserve the right to change those terms and make the new notice
provisions effective for all protected health information that we maintain. We will post and you may
request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy rights have been violated. You have the right to file a
formal, written complaint with our office or with the Department of Health & Human Services, Office of
Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office.
You will not be penalized for complaining.

Please contact us for more information, by asking to speak with our Privacy Officer or for written inquires,
note “Attention Privacy Officer”.


                                             Regina A. George, M.D.
                                            54 Scott Adam Road, #105
                                             Cockeysville, MD 21030
                                      410-666-2020 Phone / 410-666-3257 Fax

Name of Patient:           _____________________________________________________

                                               Received – Privacy Notice

Signed:                    _____________________________________________________

Date:                      _____________________________________________________
                                  Regina A. George, M.D.
                                  54 Scott Adam Road, #105
                                   Cockeysville, MD 21030
                            410-666-2020 Phone / 410-666-3257 Fax

==========================GENERAL INFORMATION==========================

Patient Last Name: _____________________ First Name: ____________________ MI: __________

Address: ___________________________________________________________________________

City: _______________________________________State: _______________ Zip code: __________

Referral Doctor Phone #: ____________________Sex (M/F): ______ Marital Status: S M D W

Birthday: (mm/dd/year) ______/______/_______ Social Security: __    ____-______ __-__________

Home Phone: _____________________________ Work Phone: _______________________________

Emergency Contact: ______________________     Emergency Phone: __________________________

Email: ____________________________________Cell Phone: ________________________________

======Primary Insurance Coverage=================Secondary Insurance Coverage======

Company: __________________________           Company: __________________________

Insured Name: ______________________          Insured Name: ______________________

Relationship: __________DOB: ________         Relationship: __________DOB: ________

Co-pay amount: _____________________          Co-pay amount: _____________________

Policy Number: _____________________          Policy Number: _____________________

Group Number: _____________________           Group Number: _____________________

Employer: _________________________           Employer: _________________________
============================Guarantor Information=============================

Guarantor: (If parents are separated, we need the contact information of each parent)


Name: ___________________________________ Name: ____________________________________

Address: ________________________________ Address: __________________________________

City: _____________________________________ City: _____________________________________

State: _______________ Zip code: ____________ State: _______________ Zip code: ____________

Home: ____-_____-_____ Cell: ____-_____-_____ Home: ____-_____-_____ Cell: ____-_____-____

Email Address: ___________________________ Email Address: ___________________________

Social Security #:______-_______-________            Social Security #:______-_______-_____________

Miscellaneous:_____________________________ Miscellaneous:_____________________________

                                   PATIENT’S AUTHORIZATION

I authorize REGINA A. GEORGE, M.D. to apply for benefits on my behalf for services rendered by
REGINA A. GEORGE, M.D. I request payment from my insurance company be made directly to
REGINA A. GEORGE, M.D. I certify that the information I have reported with regard to my insurance
coverage is correct and further authorize the release of any necessary information, including medical
information for this or any related claims. I permit a copy of this authorization to be used in place of the
original. This authorization may be revoked by me at any time in writing. I understand that nothing
herein relieves me of the primary responsibility and obligation to pay for medical services provided, when
a statement is rendered.

____________________________________                                _________________
Signature of Subscriber or Beneficiary                                    Date
                                           Family History
Patient Name:                                    Date of Birth:             Sex: Male Female
Form Completed By:       Today’s Date:           Relationship:

Name of Hospital: ___________________            Who lives in household? _____________
Illnesses during Pregnancy: No Yes               __________________________________
Medications during Pregnancy: No Yes             How many? ______
Alcohol/Drug Abuse: No Yes                       Rent? No Yes
Problems at Birth? No Yes                        Own? No Yes
Describe: ________________________               Shelter? No Yes
Type of Delivery: Vaginal C-section              Who cares for child? ________________
Birth Weight: ____________                       Date of Birth? Mother_______________
Discharge Weight: ___________                                   Father________________
Did baby receive Hepatitis B vaccine?            Are Parents Working? Mother: No Yes
     No Yes                                                             Father: No Yes
Date of Hepatitis B immunization:                Foster Care? ______Dates:___________
___________________                              Other Languages? __________________
Newborn Hearing Screen? No Yes
               FAMILY HISTORY                                 MEDICAL HISTORY
Has anyone in the family (parents, grand-        Has your child ever had:
parents, aunts/uncles, sisters/brothers) had:                                       No Yes
                                 No Yes Who?     Allergies (list): ___________      ___ ___
Allergies (list): ___________ ___ ___ _____      ________________________
________________________                         Asthma                            ___ ___
Asthma                           ___ ___ _____   Chicken Pox (Year)____            ___ ___
TB/Lung Disease                  ___ ___ _____   Frequent Ear Infections           ___ ___
HIV/AIDS                         ___ ___ _____   Vision/Hearing Problems           ___ ___
Suicide Attempts                 ___ ___ _____   Skin Problems/Eczema              ___ ___
Heart Disease                   ___ ___ _____    TB/Lung Disease                   ___ ___
High Blood Pressure/Stroke ___ ___ _____         Seizures/Epilepsy                 ___ ___
High Cholesterol                 ___ ___ _____   High Blood Pressure               ___ ___
Blood Disorders/Sickle Cell ___ ___ _____        Heart Defects/Disease             ___ ___
Diabetes                         ___ ___ _____   Liver Disease/Hepatitis           ___ ___
Seizures                         ___ ___ _____   Diabetes                          ___ ___
Mental Illness                   ___ ___ _____   Kidney Disease/Bladder Infections ___ ___
Cancer                           ___ ___ _____   Physical or Learning Disabilities ___ ___
Birth Defects                    ___ ___ _____   Bleeding Disorders/Hemophilia     ___ ___
Hearing Loss                     ___ ___ _____   Sexually Transmitted Diseases      ___ ___
Speech Problems                  ___ ___ _____   Emotional or Behavioral Problems ___ ___
Kidney Disease                   ___ ___ _____   Depression/Suicidal Thoughts       ___ ___
Alcohol/Drug Abuse               ___ ___ _____   Hospitalizations/Surgeries         ___ ___
Hepatitis/Liver Disease          ___ ___ _____   Physical/Emotional/Sexual Abuse    ___ ___
Thyroid Disease                  ___ ___ _____   Bone or Joint Injuries            ___ ___
Learning Problems/Attention ___ ___ _____        Obesity/Eating Disorders           ___ ___
  Deficit Disorder                               Other: _________________________________
Family Violence                  ___ ___ _____   ________________________________________
Other: __________________________________

Reviewed By: __________________________ Date of Review: ___________________
                                     Preventive Screening Questionnaire
Patient Name: _________________________                          History Number: __________________

Tuberculosis Risk Assessment:
(Initial visit and yearly thereafter)
            1. Was your child born in, or lived more than a
                 year in a country other than the U.S.?             ____   ____   ____   ____   ____ _____
                 Where? ________________                             Y/N   Y/N    Y/N     Y/N    Y/N Y/N
                 Year? __________________
         2.   Has your child been exposed to anyone with
              either active Tuberculosis or a history of            Y/N    Y/N    Y/N    Y/N    Y/N   Y/N
              tuberculosis disease?
         3.   Is your child living in a household with
              anyone who is HIV positive, is a substance            Y/N    Y/N    Y/N    Y/N    Y/N   Y/N
              abuser or a resident of a correctional facility?
         4.   Is your child part of a migrant worker                Y/N    Y/N    Y/N    Y/N    Y/N   Y/N
                                                                    Date   Date   Date Date Date Date
         Heart Disease/Cholesterol Screening
                                                                    ____   ____   ____ ____ ____ _____
         Is there a family history of males under 50 and
         females under 60 with high cholesterol, sudden
                                                                    Y/N    Y/N    Y/N    Y/N    Y/N   Y/N
         death, heart attack, diabetes, or strokes?
         Tobacco/Smoke Exposure
         Does anyone smoke in the house or in the child’s
         daycare/school setting?                                    Y/N    Y/N    Y/N    Y/N    Y/N   Y/N
         Fluoride Screening
         Do you have non-fluoridated well water?                    Y/N    Y/N    Y/N    Y/N    Y/N   Y/N
         Safety Screening
         Does your family have:
                 Guns in the house?                                 Y/N    Y/N    Y/N    Y/N    Y/N   Y/N
                 A fire extinguisher?                               Y/N    Y/N    Y/N    Y/N    Y/N   Y/N
                 Working smoke detectors?                           Y/N    Y/N    Y/N    Y/N    Y/N   Y/N
                 Carbon monoxide detectors?                         Y/N    Y/N    Y/N    Y/N    Y/N   Y/N

         Lead Risk Assessment (6 months to 6 years)                 Date   Date   Date Date Date Date
         1. Does your child currently live, or has he/she           ____   ____   ____ ____ ____ _____
            ever lived in a house or apartment built
            before 1960 (includes daycare center,                   Y/N    Y/N    Y/N    Y/N    Y/N   Y/N
            preschool home, home of baby-sitter or
                                                                    Y/N    Y/N    Y/N    Y/N    Y/N   Y/N
         2.   Is anyone in the home being treated or
              followed for lead poisoning?
         3.   Are there any current renovations or peeling          Y/N    Y/N    Y/N    Y/N    Y/N   Y/N
              paint in a home that your child regularly
                                                                    Y/N    Y/N    Y/N    Y/N    Y/N   Y/N
         4.   Is there a family member who is currently
              working in an occupation or hobby where
              lead exposure could occur? (auto mechanic,
              ceramics commercial painter, etc.)
                                       Regina A. George, M.D.
                                      54 Scott Adam Road, #105
                                       Cockeysville, MD 21030
                                410-666-2020 Phone / 410-666-3257 Fax

                                            Effective March 1, 2011

In view of the rising cost of Office Administration, we will begin charging a nominal fee of $10.00 to
complete all forms. This is for any kind of form – school, sports, daycare, camp, scouts, for a driver’s license,
or a form of any type. We will NOT bill your Insurance Company for this service. Please be prepared to pay
by cash or check.


Co-pays are due at the time of your visit. We accept payments by cash or check. We accept credit or debit
cards and flex-spending cards with a minimum $20 charge. We need to swipe the card, so charges can only be
done in the office. With the exception of an emergency sick call, if you do not have your co-pay, your
appointment will be re-scheduled.

You are expected to clear any unpaid balances at the time of visit. And, we can establish a payment plan for
your convenience. However, for any unpaid balances over 90 days, and not on a payment plan, a $5.00 Service
Charge will be added to your account each month past due.

There is a $25.00 charge for missed appointments and appointments cancelled giving us less than 24 hours
notice. There is a $25.00 fee for Returned Checks.


Because of frequent Insurance changes, please bring your child’s insurance card with you at each visit. We
bill your insurance incompany on your behalf. If payment is declined for any reason, we will bill you and we
expect payment to be remitted within 10 days.

Full payment is expected at time of service for patients without insurance coverage.

                                               Billing Information

Please don’t forget to let us know if you’ve had a change in address or phone number. We need to have at least
two phone numbers on file for each child.

Name of Patient: _________________________________________________________


Signed: _________________________________________________________________

Date: ___________________________________________________________________

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