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
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