Welcome to Prospect Pediatrics PA

At Prospect Pediatrics, we provide excellent health care for our patients from infancy through age 21years, in a child friendly relaxed atmosphere designed to make children and family members feel at home and safe. There is continuity of care of your child - the same doctor sees your child each visit.

MISSION STATEMENT:
At Prospect Pediatrics, Our goal is to provide an exceptional quality, comprehensive healthcare for our patients in a compassionate and respectful manner. We pledge to take care of the whole child in the context of his/her family, school and community in the highest ethical and professional level. We take that commitment serious . We feel privileged to be part of your child's life.

-At prospect Pediatrics, we listen while you talk
-Every question that you care about is important to us.
-We provide personalized care
-We simply care.

Patient Consent Form

PROSPECT PEDIATRICS PA

Patient Consent for use and disclosure of Protected Health Information

I here by give my consent for Prospect Pediatrics PA to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The notice of privacy practices provided by Prospect Pediatrics PA describes such uses and disclosures more completely.)

I have the right to review the Notice of privacy Practices prior to signing this consent. Prospect Pediatrics PA reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Director Office Operations Prospect Pediatrics PA

With this consent, Prospect Pediatrics PA may call my home or other alternative location and leave message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.

With this consent, Prospect Pediatrics PA may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”

With this consent, Prospect Pediatrics PA may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patients statements. I have the right to request that Prospect Pediatrics PA restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to allow Prospect Pediatrics PA to use and disclose my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Prospect Pediatrics PA may decline to provide treatment to me.

 
SIGNED BY: (SIGNATURE OF PATIENT OR LEGAL GUARDIAN)
DATE:
Relationship to Patient:
Print Patient's Name:
Print Name of Legal Guardian, If Applicable

Patient/Guardian must be provided with a signed copy of this authorization
form.


Address
163 Belleville Avenue Belleville, NJ 07109

Telephone
973-302-4644

Fax
973.528.2242