Consent Forms

Cinco West Pediatrics is dedicated to providing the best, evidenced-based medicine for our patients. In order to do this, a partnership based on respect and mutual trust must exist. We believe that immunizations are one of the most important health recommendations we can make on behalf of our patients. This is a life-saving intervention, and we want all of our patients to benefit from it.

We understand and respect the parents' role as the ultimate decision-makers for their child's care, but we are obligated to deliver the best and safest healthcare for the patient and our community. Our physicians subscribe to the vaccine schedule established by the American Academy of Pediatrics and the CDC, and we ask that you vaccinate your child according to this schedule.

If you do not plan to follow the immunization schedule, this may not be the right pediatrics practice for you. If you do plan to follow our recommended immunization schedule, please click "I agree" to proceed. Please feel free to discuss any concerns you may have about vaccines with us.

I hereby authorize direct payment of medical/surgical benefits to Raquel M Sagullo MD, PLLC, dba Cinco West Pediatrics, for services rendered by her in person or under her supervision. I understand that I am financially responsible for any balance not covered by my insurance. Any services rendered outside of the clinic (i.e., lab work, blood tests, x-rays, ER visits, urgent care visits) that are not covered by insurance will be my financial responsibility.

I hereby authorize Dr. Raquel Sagullo to release any medical or incidental information that may be necessary for medical care or to process applications for financial benefit.

Patient's parent, guardian, or designee is giving permission to the doctors, nurses, medical assistants, and other health care providers in this office to provide treatment for the patient.

We urge you, as the policy holder, to know your insurance plan's benefits and coverage (such as well check-ups, immunizations, co-pay or coinsurance, and referral to specialists). We will verify your benefits when you come for your first visit and when we are notified of any changes in your insurance; however, we cannot guarantee that this information will be accurate. You will ultimately be responsible for knowing what is and what is not covered by your plan.

All co-pay and coinsurance payments are due at the time of the visit.

The contract we have with your insurance company requires that payment be made within 90 days of a claim's submission. We will bill your insurance for the services rendered, but any amount not covered by your plan will be your responsibility; this amount is due immediately. Any amount outstanding on your account after 90 days may be turned over to a collection agency. No appointments can be made until your balance is paid in full.

This Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient's rights section describing your rights under the law. You ascertain that by clicking "I agree" below that you have reviewed our notice.

The terms of the notice may change; if so, you will be notified at your next visit.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA law allows for the use of health information for treatment, payment, or healthcare operations.

By clicking "I agree" below, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By clicking "I agree" below, you understand that: Protected health information may be disclosed or used for treatment, payment, or healthcare operations; the practice reserves the right to change the privacy policy as allowed by law; the practice has the right to restrict the use of health information, but the practice does not have to agree to those restrictions; the patient has the right to revoke this consent in writing at any time and all full disclosures will then cease; and the practice may condition receipt of treatment upon execution of this consent.