3
Lauren Dornquast Pullman Regional Hospital
Child - Preventive Care Visits- 2020.03.12 Palouse Health Center Palouse Heart Center
Palouse Pediatrics Palouse Psychiatry & Behavioral Health Palouse Pulmonology & Sleep Medicine
Pullman Family Medicine Palouse Health Center
Well Child/Well Baby Visit Information for Patients or Legal Guardians
Preventive care is defined as routine care in the absence of symptoms or known disease. For children, this visit is sometimes referred to as a "Well Child Check" or "Well Baby Visit" and it is very important for the growth and development of your child. Take some time to make yourself familiar with the covered benefits of your insurance plan. We highly encourage you to contact your insurance company and ask about your family's coverage. As a general rule, here are several services that may be considered preventive care during today's visit:
· Monitoring of height, weight and head circumference* (depending on patient age) · Tracking of developmental milestones · Healthy eating habits · Safe sleep recommendations · Counseling on avoiding tobacco exposure and use · Car and booster seat discussions · Reviewing stable, established problems and renewing medications that do not require changes. · Oral health examinations and fluoride application
o If your insurance does not cover the oral health exam, oral health education, or fluoride application, you
will not be responsible for these associated fees.
· Routine vaccinations (childhood immunization series)
o Your child's immunization history will be reviewed to determine if any immunizations are needed. This
clinic may use the Idaho Immunization Database (IRIS) and/or the Washington Immunization Database (Child Profile) to record the vaccinations given to the patient. Patients who receive immunizations at our clinic will be enrolled in IRIS and/or the Washington State Immunization Database (Child Profile). To opt out of an immunization database, please speak with your health care provider.
Preventive Care does not include the following:
· Evaluation of new symptoms · Testing for a new diagnosis · Significant changes to patient medical regimen
Insurance Coverage for Preventive Services
Insurance companies vary greatly in coverage for "preventive" and/or "routine" services. The variability in coverage extends to other laboratory or diagnostic testing that made be recommended based on your age or personal risk factors. We highly recommend that you contact your insurance company if you have specific questions about your coverage or benefits. We cannot guarantee benefits on behalf of your insurance company and advise you to contact your insurance company prior to receiving any services if you have concerns about potential financial responsibility.
I acknowledge that I have read and understand the information above. I understand that I am financially responsible for all charges whether or not paid by my insurance company. I further acknowledge that additional topics discussed during my preventive visit that are not preventive will result in additional fees such as a co-pay or separate office visit fee.
Printed Name of Patient:
Date of Birth:
Signature:
Date:
Lauren Dornquast Adobe PDF Library 19.12.66