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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 physician and staff bios) may also be helpful in deciding if we are a good fit for your family.

 

Requesting Records

For statements of good health for school and camp, please email us here. We check requests daily during regular business hours. Please allow up to  seven business days for your request to be completed. There is a charge of $10.00 for forms completed outside of a scheduled appointment. We are able to expedite the completion process to one-two business days as our staffing allows. Expedited form completion carries a charge of $25.00. 

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.

 

Vaccine Records
Copies of vaccine records can be obtained through the Patient Portal,  or by emailing us here. We check requests daily during regular business hours. If you are having any difficulties accessing your child’s portal, please call our office at 512-467-7334 and one of our staff will assist you.

 

Forms

Form Name Type Description
Flu Vaccine Questionnaire Form This completed form is required for all patients and parents who are receiving a flu shot from GROW. DOWNLOAD
New Patient Paperwork- Family Forms Packet Please review ALL policies and sign these forms including: Demographics, Medical History Questionnaire, Consent to Treat, Financial Policies, Office Policies, Records Request, and ImmTrac Registration. DOWNLOAD
Adolescent Patient HIPAA Consent and Release Form For patient’s age 16 and older, this form gives our adolescent patients the option to grant or restrict access to their personal health information. DOWNLOAD
Consent to Treat Form Authorizes our practice to provide care to your child if a parent/legal guardian unable to make an appointment and permits another individual (grandparent, nanny, etc.) to be present. 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
ADHD Initial Questionnaire Form Vanderbilt Assessment Scale DOWNLOAD
ADHD Follow-up Questionnaire Form NICHQ Vanderbilt Assessment Follow-up DOWNLOAD

 

Policies and Practices

Form Name Type Description
Adolescent Confidentiality Policy Disclosure Explains our support of confidentiality with our adolescent patients and how we promote the collaboration between patient, parent, and provider. DOWNLOAD
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 Administrative/Forms Fees Disclosure Informs you of fees for forms completion outside of an appointment. 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.

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