Policies, Practices & Forms for GROW Patients

 

Please read our policies!

If you are a GROW family, or plan to be, please take some time to review ALL of our policies posted here – we have done our best to keep them as simple and easy to review as possible (while retaining all pertinent info). This information (along with the provider and staff bios) may also be helpful in deciding if we are a good fit for your family.

 

Requesting Records/Letters/Vaccine Records

If you plan to request records from another provider to send to GROW, or vice versa, please use the Medical Records Request. You may then email the form to us at records@growpediatrics.com.

If you would like to give GROW permission to share any of your child’s records with a school/daycare/camp, please use the School/Daycare Release. You may then email the form to us at records@growpediatrics.com.

 

New Patients – Newborns

If you are new to GROW with a brand new bundle, please review ALL policies and sign these forms:

  1. Acknowledgement of Notice of Privacy Practices
  2. Newborn Insurance Waiver
  3. New Patient Demographics
  4. Financial Policy

 

New Patients – Babies & Children (transferring from another practice)

If you are transferring to GROW from another practice, please review ALL policies and sign these forms:

  1. Acknowledgement of Notice of Privacy Practices
  2. New Patient Demographics
  3. Medical Records Request (or you may request records directly with the previous practice)
  4. Financial Policy

 

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
School/Daycare Release Form Authorizes our practice to release patient information (Immunization Records, Statement of Good Health, etc.) to a specified third party. 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
Notice of Administrative/Forms Fees Disclosure Informs you of fees for form completion outside of an appointment. 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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