Gerald R. Jerkins MD
UT Le Bonheur Pediatric Specialists
Memphis Tennessee

Office Information Form

Click here to download the Patient Information Form as a PDF, or fill it out online using our secure Hushmail form below.

* Indicates required fields.

Patient's Information

*Patient Name
*Birth Date
*Sex
*Address
*City
*State
*Race
*Zip
*SSN
Drug Allergies



Parent / Legal Guardian Information

Father's Information

*Name
SSN
 
Address
City
State
Zip
Home Phone
Secondary Phone
*Employer
*Employer Phone
 


Mother's Information

*Name
SSN
 
Address
City
State
Zip
Home Phone
Secondary Phone
*Employer
*Employer Phone
 


Emergency Contact (Not parents)

Name
Phone



Primary Care Physician

Name
Phone



Referring Physician

Name
Phone




WE APPRECIATE PAYMENT AT THE TIME OF SERVICE.
WE ARE UNABLE TO FILE INSURANCE WITHOUT A COPY OF YOUR CARD


Primary Insurance Company

*Insurance Company
*Policy / ID Number
*Name of Policy Holder
*SSN
*Group #
*Address for Claims
*Phone #
   


Secondary Insurance Company

Insurance Company
Policy / ID Number
Name of Policy Holder
SSN
Group #
Address for Claims
Phone #
   


Consent to Treat

Kids Urology recognizes the need for a clear understanding between patient, legal guardian and medical provider regarding protected health information and financial arrangements for healthcare. The following information is provided and requested to avoid any misunderstanding concerning health information and payment for professional services.

I hereby authorize Kids Urology to provide medical care to my child, listed below, including examinations and treatments both within its office and at other locations. I certify that I am the legal parent or guardian; I understand that Kids Urology assumes that a child's biological and / or legal parents are both legal guardians who have access to medical information and treatment options for that child. Any child brought to our office by someone other than the child's parents or legal guardians for examination or treatment must have a signed authorization from the parents or legal guardians. This authorization gives Kids Urology the right to share the child's protected health information with the person(s) who accompanies the child to our office.

Financial Policy / Consent

1. PAYMENT: Payment is expected at the time of service. If your deductible has not been met, or a percentage is your responsibility, we expect payment when services are rendered. Even though insurance will be filed, you are responsible for any balance after insurance processes your claim. All charges for treatment become due and payable sixty (60) days after the date of service. This period allows sufficient time to process insurance and makes payment in full of any remaining balance. If not paid within 60 days Kids Urology will begin various collection activities including, but not limited by submitting the past due account to a collection agency. There will be a $25.00 charge for all return checks.

2. SELF PAYMENT (Private, cash payment): If you have no insurance coverage we ask that you coordinate your child(ren) visit with our business office prior to your child(ren)s office visit or surgery. We require advance payment for professional services. We require full payment for office visits.

3. MANAGED CARE: ALL MANAGED CARE (HMO, PPO, etc.) co-payment amounts are due at the time of service. You will be charged $10.00 rebilling fee if you do not pay your co-pay when services are rendered.

Because we do not have access to each employer's guidelines and stipulations, we must rely on you, the parent or legal guardian, to inform us each time of service exactly what those guidelines and stipulations are. The patient, parent or legal guardian is responsible for getting the current information about your insurance coverage. It is your responsibility to make sure we are in network, if not you must obtain out of network approval. If your insurance plan requires a referral authorization from a primary care physician please present this at your initial visit. If you request an office visit or surgery without a referral authorization your insurance plan may deem this as "out of network" or "non-covered" treatment, and you will be responsible for a larger amount or all of the charges. By signing below, you acknowledge that it is the parent or legal guardian's responsibility to be aware of what services are covered and agree to pay for any service deemed to be non-covered or not authorized by the plan. Unfortunately, if you do not inform us of any special requirements in your insurance contract such as lab work, screening, preventative care, hospitalization, and / or out- patient procedures that are non-covered or must go to a specific location, or the need for a referral from your primary care physician, we have no choice but to bill you directly for those charges. Payment for those charges is then your responsibility. Some insurance carriers do not cover some procedures and supplies. Please make certain you understand which aspects of your treatment are covered before proceeding. In this rare case you may be asked to sign a waiver form, which states that you understand that you will be responsible for these charges. Please check with your insurance if you have any questions relating to the services we provide. We want you to receive all of the benefits offered to you by your insurance company.

4. SECONDARY INSURANCE: Kids Urology requires the patient to provide secondary insurance information to the provider if applicable. Patient agrees to provide such information as outlined below. Patient agrees to notify provider in the future immediately of any additions, changes, or deletions in primary or secondary insurance coverage. Answer by checking below as applicable.

I have no secondary insurance coverage.

I have secondary insurance coverage as coverage as described on the attached Patient Demographic form.

5. CHILDREN OF DIVORCED PARENTS: Responsibility for payment for treatment of minor child(ren), whose parents are divorced, rests with the parent who seeks the treatment. Any court ordered responsibility judgment must be determined between the individuals involved, without the inclusion of Kids Urology.

Medical Records / Privacy

At Kids Urology we are committed to protecting the security & privacy of your child's personal information. Medical records are our property, kept in a secure location, and are accessed only for purposes outlined by the Notice of Private Practices. Records may be released or shared with other health care providers for treatment of your child. Patients are entitled to a copy of their medical records only if authorization for release is signed below. There is a fee for copies of patient's records.

  • I understand that Kids Urology may call my home, cell phone and place of employment for healthcare reasons, appointment reminders, to resolve billing issues, and to mail informational postcards to my home address, as well as billing information requested verbally by me.
  • I understand that Kids Urology may leave messages on my answering machine regarding appointments and limited lab information.
  • I authorize Kids Urology to discuss my child's medical case with adults or other minors present during the visit regardless of whether I am present.
  • I understand that if I send photograph(s) of my children, or any signed artwork created by my child(ren) they may be displayed within the office of Kid's Urology.
  • I understand that Kids Urology will fax or mail letters of consultation and other information to my child's primary care or referring physician.
  • I authorize to release my child(ren)s medical records and to obtain medical records from any Physician, Pharmacy, or Healthcare provider or facility to better assist in my child(ren) care.

I have read and acknowledge the Consent to Treat, Financial Policy, and Medical Privacy. I also understand that a copy of your Notice of Privacy Practices (HIPAA) may be made available upon my request. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at 1920 Kirby Parkway, Suite 100 Germantown, TN. 38138 to restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

Kids Urology firmly believes that a good patient / physician relationship is based upon understanding and open communications. It is our hope that the above policies will allow us to provide the highest quality care to your child. If you have any questions or need clarification regarding these policies please call us at (901) 751-0500.