Forms

Form Name	Type	Description
Acknowledgement of Notice of Privacy Practices	Form	Acknowledges that the “Notice of Privacy Practices” was made available to you prior to any services being rendered, and your consent to the use and disclosure of the information as described.	DOWNLOAD
Newborn Insurance Waiver	Form	Acknowledges that your child’s coverage is not in effect until your insurance information is submitted and verified, as well as your financial obligations and responsibilities.	DOWNLOAD
New Patient Demographics	Form	Standard new patient information.	DOWNLOAD
Medical Records Request	Form	Authorizes the release of medical records to or from our practice.	DOWNLOAD

Policies and Practices

Form Name	Type	Description
Financial Policy	Disclosure	Notifies you of our policies regarding the financial responsibilities associated with services rendered to your child, in compliance with the Federal Consumer Protection Act.	DOWNLOAD
Notice of Privacy Practices	Disclosure	Describes how medical information about you may be used and disclosed and how you can get access to this information.	DOWNLOAD
Vaccine Policy	Disclosure	Describes our commitment to vaccinations for disease prevention and our ethical reasoning for this policy.	DOWNLOAD
Vaccine Schedule	Disclosure	Lists our interpretation of the CDC recommended vaccine schedule.	DOWNLOAD
Website Privacy Policy	Disclosure	Informs you of our goals and intentions for this website. Your use of the site implies your consent to this policy.	DOWNLOAD