Welcome to Pediatric Associates of Dallas

In order to comply with Federal Health Insurance Portability and Accountability Act (HIPAA) regulations, effective April 14, 2003, every family will be required to complete the new registration forms for our records.  Please complete both the registration portion of the form and the financial agreement. The Notice of Privacy Policy will outline your rights regarding the release of Protected Health Information (PHI) and a signature line is provided that you have received this policy. We ask that you complete the information thoroughly and accurately, as incomplete forms will be returned to you and may delay your appointment.

When completing the information, we would like to clarify the definition of the “Responsible Party”. The “Responsible Party” is considered the “Custodial Parent” for the child/children and not the “Insured Party”. The address on your account will be the primary residence of the child and will be used for billing purposes and any other correspondence from our office. We do not bill “Non-Custodial” parents for charges due to our office. The “Custodial” parent is responsible for payment of balances in full to our office. Forwarding statements and recovering any portion of balances payable by a “Non-Custodial” parent due to court order, is the responsibility of the “Custodial” parent. Our office does not have the authority to enforce a “Non-Custodial” parent’s financial obligation to the “Custodial” parent.

If anyone other than a parent or legal guardian will be accompanying your child to his or her appointments (grandparents, nannies, etc.), as the legal guardian for the child you are required to complete a separate authorization form under Federal Law. Should this apply to your family, please ask our front desk staff for an Authorization Form.

We would like to thank you in advance for your cooperation in these matters and remind you that our ultimate goal is to provide our patients with quality health care.

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