Register New PatientIPHC new patient registrationPlease enable JavaScript in your browser to complete this form.How did you hear about IPHC? *Parent #1 First Name *Parent #1 Last Name *Parent #1 date of birth (mm/dd/yyyy) *Parent #1 cell *Parent #1 email address *Parent #2 First Name (if n/a please enter n/a) *Parent #2 last name (if n/a please enter n/a) *Parent #2 date of birth (if n/a please enter n/a) *Parent #2 cell ((if n/a please enter n/a) *Parent #2 email address (if n/a please enter n/a) *Street Address of Patient/Parent #1 (street, city, state, zip) *Is the address the same for patient and parent #2? *YesNoN/AEnter Address of Parent #2Section 2: Child InformationDo you have any children who currently come to IPHC? *yesnoChild's name/date of birth (of current client) *Are you registering a newborn? *YesYes and siblingsNoThere are specific requirements IPHC has related to newborns if you plan to be a client. Please read the following and verify your agreement before proceeding to register your newborn and/or siblingsVitamin K Injection (read requirement below) *I agree to this requirement and will/have obtained Vitamin K injectionI do not understand and have questions for providerIPHC requires that any newborn client receive the Vitamin K injection at birth. This is a routine injection given to all newborn unless a parent declines. Injectable vitamin K is a life saving intervention that reduces the risk of bleeding complications for infants from birth until about 6 months. If you elect to decline vitamin K, we will not accept the newborn as a client at IPHC due to safety concerns. This includes oral vitamin K which is not a proven alternative to the injection.enter the newborn's anticipated first & last name and birth sex *(if unknown enter last name and babyboy, babygirl, or baby)Newborn's due date or date of birth *Please list birth facility/hospital/homebirth midwife *Please list any complications with pregnancy or postpartum thus far or any anticipated special health care needs for the newborn (i.e. cardiology, kidney recheck, etc) *Any other children to register? *yesnowe have other children but they will not be transferring care due to custody issues Child(ren) informationPlease enter your child(ren)'s information; click the + sign at the end of the row to add more childrenFirst & Last Name *Date of Birth *Any health conditions? *i/e asthma, autism, feeding issues, sensory problems, mental health or ADHD diagnoses etcBirth Sex *MaleFemalemulti/ambiguous Previous Pediatrician *(name, location, phone # and fax if possible)Approximate date of last well visit *please list for all children you're registering same patient the Policy InformationPlease Review and select your response below regarding office policiesIPHC requires all children in the same home will be seen/transferred to IPHC. This is for safety, continuity of care, and legal reasons *I understandI have extenuating circumstances to discuss (like step-children, or kids living in the home who are in foster care etc)IPHC providers require all clients to obtain the routine pediatric vaccinations recommended by the AAP (previously the CDC schedule before rule changes in 2025 from RFK). We do not endorse alternative or selective vaccine schedules. We are always happy to discuss this and provide education prior to immunizing. (does not include Flu, COVID, although those are recommended) *I agree to follow the routine pediatric vaccination scheduleI don't understand and/or have questions for a providerI have a Medical Exemption and need to speak with a providerIPHC requires that all clients follow the routine wellness schedule endorsed by the AAP. Our providers will notify you if you have missed a well visit. Multiple missed well visits without a discussion may result in dismissal from the practice *I understandI do not understand and/or have questionsInsurance InformationInsurance Carrier (i.e Cigna, Aetna, BCBS, United, Tricare, Health Share, Self Pay or Other) *Policy Holder Name *Policy/Member ID# *If Policy IDs are different for each child; please enter each child's name & policy # separatelyPolicy Group # (or N/a) *Do you have secondary Insurance *YesNoSecondary Insurance Carrier, Policy # and Group # *Have you verified that IPHC is in network for your insurance plan? *Yes-IPHC is in networkIPHC is out of network, we will self payI don't know/need helpTo validate if IPHC is in network please log on to your insurance member portal and/or call the customer service # for your plan and searching for Integrative Pediatric Health Care or by provider (Mary Enzman Hines CPNP or Jennifer Gaughan CPNP). Please ensure they have us at our address 3540 S Poplar St #202 Denver CO 80237. If they say they cannot verify or aren't sure, please have them do a conference call with our office. If we are out of network YOU ARE RESPONSIBLE FOR ALL CHARGES AT TIME OF SERVICE. We are unable to verify this for you due to the complexity of networks and contracts.Insurance Card Drag & Drop Files, Choose Files to Upload Please upload front and back of your insurance cardDrivers License Drag & Drop Files, Choose Files to Upload Please upload photo of parent's Drivers licenseMedical Records Form DownloadPlease download this form so we can obtain records from your previous provider. (you can use Adobe Fill and Sign--a free app-- or print, scan and upload in the section below)Click here for medical records formMedical Records/Release of Information Drag & Drop Files, Choose Files to Upload Please upload the release of information form, one for each child. If you cannot upload it here please email it to admin@iphcdenver.comSubmit
