Fillable Labor and Delivery Pre-Registration Cover Sheet

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Labor and Delivery Pre-Registration Cover Sheet

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034920 | 04/2019
PATIENT’S INFORMATION
Patient’s name:
Date of birth (mm/dd/yyyy):
Expected date of delivery (mm/dd/yyyy):
Date and time of online registration
(mm/dd/yyyy hh:mm am|pm):
Be sure to include: Notes:
Expectant Mother’s Photo ID
Expectant Mother’s Insurance card(s) (front & back)
Expectant Mother’s Prescription card
Father/Partner’s Insurance card(s) (if applicable)
Acknowledgment of Notice of Privacy Practices form
Permission to Call Mobile Phone form
MyChart Proxy Access Request form
Terms & Conditions of Service form
Outpatient Terms & Conditions of Service form
Advance Directive Status form
Advance Healthcare Directive (if you have one)
MAIL TO: Lucile Packard Children’s Hospital Stanford
Attn: Admitting Department
OB Pre-Registration Forms
725 Welch Rd, Ground Floor, Suite G26
Palo Alto, CA 94304
Admitting Telephone Number
() -
Admitting Fax Number
() -
Lucile Packard Children’s Hospital Stanford
Labor and Delivery Pre-Registration Cover Sheet
FAX TO: () -
STANFORD HOSPITAL and CLINICS
LUCILE PACKARD CHILDREN’S HOSPITAL
STANFORD, CALIFORNIA 94305
ADMIN ACKNOWLEDGEMENT OF
NOTICE OF PRIVACY PRACTICES
Addressograph or Label - Patient Name, Medical Record Number
Medical Record Number
Patient Name
15-2122 (9/13)
By signing this form, you acknowledge receipt of the Notice of Privacy Practices of Stanford Hospital and
Clinics and Lucile Packard Children’s Hospital. Our Notice provides information about how we may use
and disclose the health information that we maintain about you. We encourage you to read our full Notice.
ACKNOWLEDGEMENT OF RECEIPT: I acknowledge receipt of the Notice of Privacy Practices of Stanford
Hospital and Clinics and Lucile Packard Children’s Hospital.
Patient, Parent or Personal Representative
Signature: Print Name: Date: Time:
If other than the patient, specify relationship: ____________________________________________
If interpreted: ____________________ __________________ ___________________
Interpreter Signature Print Name Language
___________ _____________ _________________________________
Date Time Position/Relationship to Patient
DATOS PRINCIPALES • ACUSO DE RECIBO DE LA NOTIFICACIÓN DE PRÁCTICAS DE PRIVACIDAD
Al fi rmar este formulario, usted confi rma haber recibido la Notifi cación de las Prácticas de Privacidad
de Stanford Hospital and Clinics y Lucile Packard Children’s Hospital. Nuestra Notifi cación proporciona
información sobre cómo podemos usar y divulgar la información de salud que mantenemos sobre
usted. Le recomendamos leer nuestra Notifi cación completa.
ACUSO DE RECIBO:
Confi rmo haber recibido la Notifi cación de las Prácticas de Privacidad de
Stanford
Hospital and Clinics y Lucile Packard Children’s
Hospital.
Paciente, Padre, Madre, Representante Personal
Firma: Nombre Impreso: Fecha: Hora:
Signature Print Name
Date Time
Si no fi rma el paciente, indique su
r
elación con él:
FOR HOSPITAL USE ONLY: INABILITY TO OBTAIN ACKNOWLEDGEMENT
If the Hospital is not able to obtain the patient’s acknowledgement, record the good-faith effort made to
obtain acknowledgement, and the reason acknowledgement was not obtained:
Effort to obtain acknowledgement:
K In-person request K
Request via mail (send copy of letter to HIMS for inclusion in patient’s record)
K Request via e-mail K Other: ____________________________________________________
Reason acknowledgement was not obtained:
K
Patient refused to sign
K Patient did not return acknowledgement via mail, e-mail
K
Patient unable to sign
K Other: ____________________________________________________
Staff:
Signature Print Name Date Time
Lucile Salter Packard Children’s Hospital
STANFORD UNIVERSITY MEDICAL CENTER ● 725 Welch Road, Palo Alto, CA 94304
*L15571*
CONSENT-PERMISSION TO CALL MOBILE PHONE
Medical Record Number
Patient Name
Addressograph Stamp – Patient Name, Medical Record Number
L15571 (10/15)
Our Billing Process
Thank you for choosing Stanford Children’s Health as your health care provider. We want to make sure you
understand our billing process. We follow the process below to ensure that your claims are paid correctly
and timely.
If you have insurance:
We will bill your insurance first. Any deductible/co-insurance/co-pay are patient/guarantor’s
responsibility.
If you have a secondary insurance, we will bill any deductible/co-insurance/co-pay deemed
patient/guarantor’s liability after billing your primary insurance to your secondary insurance.
If your secondary insurance also has deductible/co-insurance/co-pay, these will be billed to the
guarantor after the claim has been processed and paid by your secondary insurance.
You will receive a copy of the Explanation of Benefits (EOB) from your insurance when they
process/pay claims submitted to them. Please review and keep for your records. It will explain
how the claim was processed and if and why you have any liability.
*If you have any questions about your coverage and benefits or why you have a liability on a claim, please contact your insurance for clarification. Please note
that some claims takes longer to process than others. In some cases, we have to send an appeal to insurance if claims are not paid correctly.
If you do not have insurance:
You will be billed for the services
If you have any questions regarding your bill, contact our customer service department at
(800)308-3285, Monday – Friday from 8:00AM -5:00PM
It is important that the information we have on file is current and accurate, especially your demographic and
insurance information. Please let the front desk representative know if there are any changes to your
information so we can update your records accordingly.
By signing below you acknowledge you have been advised of our billing process, and if the primary contact
number we have on file for you is a mobile telephone number, you agree that we, Stanford Children’s
Health, our agents, contractors or collection agency may call you using this mobile number using an
automatic telephone dialer and/or leave you a pre-recorded and/or text messages on the mobile number. This
consent form will remain active unless the guarantor of the account (signee) provides a written request to
terminate this consent or the guarantor is changed on the account.
If you choose not to sign below, please provide us with an alternative phone number to use to communicate
billing information to you. PLEASE NOTE: If neither a signature nor an alternate number is provided, you
will continue to be liable for any amounts designated as patient liability.
Print Name: ______________________________________
Signature: _______________________________________ Date: ____________________
Lucile Packard Children’s Hospital
STANFORD UNIVERSITY MEDICAL CENTER
725 Welch Road Palo Alto, CA 94304
*L15499*
CONSENT • MYCHART PROXY ACCESS REQUEST
M
edical Record Number
Patient Name
Addressograph or Label
L15499 Rev (05/14)
MyChart Proxy Access Request Form- Request for Online Access to Medical Records
I hereby request Lucille Packard Children’s Hospital Stanford/Stanford Children’s Health provide access to health
information in MyChart allowable by law, of the minor patient named below to the following proxy representative.
Please note the following age range limitations for MyChart. These age range limitations do not affect any legal
right you have to access your child’s records by other means. To request a copy of your child’s record, contact the
medical records department.
• I
f your child is age 0-11: You will be granted full access to your child’s MyChart record, a subset of
complete medical records
• If your child is age 12-17: You will be granted partial access to your child’s MyChart record.
(e.g. immunizations, messaging)
• Once your child reaches age 18, you will no longer have access to your child’s MyChart record.
P
lease print legibly and complete all fields to ensure timely processing.
MEDICAL RECORD ACCESS REQUEST
Patient Name:
__________________________ ___________________________
First Last
Date of Birth: _______________ MRN: _____________________
to patient:
Parent
Other
____________
Are you the
legal
custodian*?
Yes
No
*Legal documents may be required, such as a birth certificate, guardianship papers, adoption documents, etc.
REQUESTOR INFORMATION (Parent/Legal Guardian)
Your Name: _________________________________ _________________________________
First Last
Street Address: ________________________________________________________________
City: ____________________________ State: ______________ Zip Code: _____________
Phone: ____________________ Date of Birth: ____________________
Email: _______________________________________________________________________
Your Signature: ____________________________________ Date: _____________________
FACILITY USE ONLY
Date Received:
Proxy MRN:
Patient Relationship Verified By: _______________________________ _________________
Name
Phone Number
Proxy Access Approved: Yes No Letter Sent: Yes No Date Sent: __________
Form FAXED to HIMS for processing
Lucile Packard Children’s Hospital Stanford
STANFORD UNIVERSITY MEDICAL CENTER ● 725 Welch Road, Palo Alto, CA 94304
CORE DATA • OUTPATIENT TERMS AND
CONDITIONS OF SERVICE
Medical Record Number
Patient Name
Addressograph Stamp – Patient Name, Medical Record Number
L14315 6735 (8/17)
Page 1 of 2
White - Medical Records Yellow - Patient Copy
Please read this document carefully. Lucile Salter Packard Children’s Hospital (LPCH) requires the
Terms and Conditions of Service to be signed in its entirety, without alteration.
1. AUTHORIZED SIGNATURE. You may sign this form only if you are a competent adult over the age of 18 or a
minor who is permitted under state law to consent to treatment. If you are a minor who does not fall within the
limited exceptions provided under state law or are not competent to sign this form, the form must be signed by
a properly designated representative, such as a parent or legal guardian.
2. TERM OF AGREEMENT. The terms and conditions in this outpatient agreement will remain in effect for one
year from the date of signature. You will be asked to sign this agreement annually. At each clinic visit, you
will be asked to confirm that your demographic and insurance information is correct. If your insurance or
demographic information has changed, please inform the clinic staff.
3. MEDICAL CONSENT. I, the undersigned, consent to the general treatment and procedures that may be
performed during this hospitalization or as an outpatient (including emergency services). These procedures
may include but are not limited to laboratory procedures, x-ray examinations, medical or surgical treatment or
procedures, anesthesia, or hospital services provided to the patient under the general and special instructions
of the patient’s physician or surgeon. I understand that it is the responsibility of the patient’s physician to
obtain the patient’s informed consent when required for specific medical or surgical treatment and special
diagnostic or therapeutic procedures. I understand and agree that at the request of the attending physician,
allied health practitioners (such as physician assistants and nurse practitioners) may participate in the patient’s
care.
4. TEACHING INSTITUTION. LPCH is a teaching facility, training physicians, surgeons, nurses and other health
care personnel. At the request, and under the supervision, of the attending physician, I agree that residents,
interns, medical students, post-graduate fellows, visiting faculty members and other health care personnel in
training may participate in the care of the patient. Certain medical services may be provided by individuals
who do not have a physician’s certificate but are qualified to participate in a special program as a visiting
faculty member.
5. PHOTOGRAPHY. I consent to the taking of pictures, videotapes or other electronic reproductions of the
patient’s medical or surgical condition or treatment, and the use of the pictures, videotapes or electronic
reproductions, for treatment or internal or external activities consistent with the Hospital’s mission, such as
education and research, conducted in accordance with Hospital policies.
6. LEGAL RELATIONSHIP BETWEEN LPCH AND PHYSICIANS. Except for those physicians under contract with
LPCH, such as faculty physicians practicing in the clinics, all physicians and surgeons furnishing services
to the patient are independent contractors with the patient and are not employees or agents of LPCH. The
undersigned understands that the patient is under the care and supervision of his or her attending physician
and that it is the responsibility of LPCH and its non-physician health care staff to carry out the instructions of
such physician or surgeon.
7. JOINT INFORMATION. The undersigned understands that patient information and records may be shared
between Stanford Hospital and Clinics and LPCH to facilitate patient care.
8. FINANCIAL AGREEMENT. For the services to be rendered (e.g., hospital, physician), the undersigned agrees
to accept full financial responsibility for the patient’s account in accordance with the regular rates and terms
of LPCH. This includes financial responsibility for all deductibles and copayments that may be required
by the patient’s insurance or health plan, including Medicare and Medi-cal. Should the patient’s account(s)
be referred to an attorney or a collection agency for collection, the undersigned further agrees to pay actual
attorneys’ fees and lawsuit-related expenses incurred in addition to other amounts due. When the services are
to be billed to insurance, a health plan or another payment source, then paragraphs 9 (Contracted Health Plan
Patients and Other Sources) and/or 10 (Assignment of Insurance Benefits) will also apply.
Lucile Packard Children’s Hospital Stanford
STANFORD UNIVERSITY MEDICAL CENTER ● 725 Welch Road, Palo Alto, CA 94304
CORE DATA • OUTPATIENT TERMS AND
CONDITIONS OF SERVICE
Medical Record Number
Patient Name
Addressograph Stamp – Patient Name, Medical Record Number
L14315 6735 (8/17)
Page 2 of 2
White - Medical Records Yellow - Patient Copy
9. CONTRACTED HEALTH PLAN PATIENTS AND OTHER SOURCES. The undersigned understands that the
patient may be eligible for certain health care coverage through a health plan (HMO, PPO) on the list
of health plans with which LPCH contracts, or through some other source (e.g., clinical trial sponsor,
employer’s workers’ compensation insurance). The undersigned agrees to be responsible under paragraph 8
(Financial Agreement) for paying the patient’s account: (a) if LPCH does not contract with the health plan;
(b) for any copayment and deductible; (c) for services not approved by the health plan or other source; or (d)
for services not covered and/or paid for by the patient’s health plan or other source.
10. ASSIGNMENT OF INSURANCE BENEFITS (INCLUDING MEDICARE BENEFITS). The undersigned authorizes
direct payment to LPCH of any insurance benefits otherwise payable to or on behalf of the patient for
outpatient services at a rate not to exceed the actual institutional and professional charges. The undersigned
understands and agrees that he/she is financially responsible under paragraph 8 (Financial Agreement)
for charges not paid in accordance with this assignment. If applicable, the undersigned further attests that
information given to LPCH to assist the patient in applying for payment under the Medicare or Medical
programs is correct.
The undersigned certifies that he/she has read both pages of the Outpatient Terms and Conditions of
Service, has received a copy of it, and is the patient or is duly authorized by or on behalf of the patient to
execute and accept its terms.
______________________________________________ __________________ ______________________
Patient or Responsible Person Signature Date/Time Witness
Relationship to Patient: q Parent With Legal Custody q Patient Authorized to Consent
q Legal Guardian/Temporary Legal Guardian. Explain type of guardianship: ________________________
q Official documentation of guardianship/temporary guardianship received (e.g., court papers)
q Person with Written Authorization (e.g., Caregiver’s Authorization Affidavit, Third Party Authorization,
Durable Power of Attorney). Explain type of written authorization _______________________________
q Documentation of written authorization received
IF INTERPRETED: ___________________________ ________________________ ______________________
Interpreter Signature Print Name Language
___________________________ __________________
Position/Relationship to Patient Date/Time
FINANCIAL RESPONSIBILITY AGREEMENT BY PERSON OTHER THAN THE PATIENT
OR THE PATIENT’S LEGAL REPRESENTATIVE:
I agree to accept full financial responsibility for services rendered to the patient and to accept the terms of the
paragraphs on Financial Agreement (8), and, if applicable, Contracted Health Plan and Other Sources (9) and
Assignment of Insurance Benefits (10) above.
____________________________________ _______________________ ______________ ______________
Financially Responsible Party Relationship to Patient Date/Time Witness
PLEASE SEE THE NOTICES REGARDING RELEASE OF INFORMATION ON THE BACK SIDE OF THIS PAGE
RELEASE OF INFORMATION
In compliance with the federal privacy regulations under the Health Insurance Portability and Accountability
Act (HIPAA), Lucile Salter Packard Children’s Hospital provides patients with its Notice of Privacy Practices,
which describes how medical information about patients may be used and disclosed, and how patients can
access this information. Copies of the Notice of Privacy Practices are available at any registration desk, in the
Patient & Visitors section under Patient Services of our website www.lpch.org or by calling the Lucile Salter
Packard Children’s Hospital’s Privacy Office at 650-724-4722.
FINANCIAL ASSISTANCE AVAILABLE
Lucile Packard Children’s Hospital has a variety of financial assistance options available to patients who
are uninsured or underinsured. Lucile Packard Children’s Hospital will assist patients in determining
if they qualify for financial assistance or if there are programs available that may help pay for medical
services. Additional information and/or a statement of charges for services provided by Lucile Packard
Children’s Hospital can be obtained by contacting the Customer Service Unit of Patient Financial Services
at 800-549-3720.
Financial assistance applications are available at all Packard clinics and hospital registration areas. The
application can also be found on our website at www.lpch.org in the Patients and Visitors section under
Financial and Insurance Information or by calling the customer service number above. Applications are
reviewed to determine what assistance may be available; applicants are notified of the outcome of this
review within 10 business days after the completed and signed application is received.
Patients who qualify may receive assistance with bills for services provided by Lucile Packard Children’s
Hospital and by physicians employed by Stanford University. Services may include inpatient and
outpatient care, emergency services, co-payments and deductibles, non-covered charges, denied days and
stays, and other special circumstances. Patients who have no insurance or inadequate insurance and meet
certain low- and moderate- income requirements may qualify for discounted payment or charity care.
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Labor and Delivery Pre-Registration Cover Sheet

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Completed 24 June 2021

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