New Patient Packet Form URLThis field is for validation purposes and should be left unchanged.1. Patient Registration / Intake FormPatient Full Name:Date of Birth: MM slash DD slash YYYY Primary Address:City/State/Zip:Parent/Guardian Legal Name:Legal Custody Status (if applicable):Primary Phone:Secondary Phone:Email Emergency Contact (Non-guardian):Pharmacy:I attest that I am the legal guardian or authorized representative of the above-named minor.2. Comprehensive Pediatric Medical HistoryComplete birth, developmental, medical, surgical, and psychiatric history must be disclosed. Failure to provide accurate information may impact care delivery.Past Medical Conditions:Hospitalizations:Surgeries:Current Medications (include OTC/supplements):Drug/Food/Environmental Allergies & Reactions:Immunization Status:Family History (hereditary conditions):Social Determinants (smoke exposure, housing concerns, etc.):3. HIPAA Privacy Notice AcknowledgmentI acknowledge receipt of Brightside Care’s Notice of Privacy Practices. I understand my child’s protected health information (PHI) may be used for treatment, payment, and healthcare operations. I understand I may request restrictions in writing, though Brightside Care is not required to agree. SignatureDate MM slash DD slash YYYY 4. Insurance Authorization & Assignment of BenefitsI authorize Brightside Care to release necessary medical information to insurers. I assign all insurance benefits directly to Brightside Care. I understand verification of benefits does not guarantee payment. I agree to pay all balances not covered by insurance. SignatureDate MM slash DD slash YYYY 5. Informed Consent for TreatmentI consent to medical evaluation, diagnostic testing, immunizations, procedures, behavioral assessments, ADHD management, and autism evaluations as deemed medically necessary. I acknowledge that medicine is not an exact science and no guarantees have been made regarding outcomes. I understand risks, benefits, and alternatives have been explained to my satisfaction. I consent to emergency treatment if immediate intervention is required. SignatureDate MM slash DD slash YYYY 6. Financial Policy & Payment AgreementPayment is due at time of service unless prior arrangements are made. Copays, deductibles, and coinsurance are patient responsibility. Accounts over 60 days may incur collection activity and associated fees. A 24-hour cancellation notice is required. Missed appointment fees may apply. I agree to pay reasonable attorney and collection fees if account defaults. SignatureDate MM slash DD slash YYYY 7. Authorization for Release of InformationI authorize Brightside Care to obtain and/or release medical records for purposes of continuity of care, payment, or healthcare operations. This authorization remains valid for 12 months unless revoked in writing. I understand revocation does not apply to information already released. SignatureDate MM slash DD slash YYYY 8. Telehealth ConsentI consent to telehealth services via secure electronic communication. I understand potential risks include technical failure and data breach despite safeguards. I understand telehealth services are billed consistent with payer policies. I confirm I am physically located in the state of North Carolina during telehealth visits unless otherwise authorized. SignatureDate MM slash DD slash YYYY
