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Fillable Patient Forms

New Patient Form

2024 - Updated Demographics and Billing Policy

For all existing patients - to provide us with your most updated demographics and inform you of the new billing policies

Release of Medical Records Form

Provide consent to send or request medical records to/from any doctor's office, hopital, school or facility.

Individual Forms

Demographics

HIPAA

Immtrac

Billing Policy

Demographics and Billing Policy

If you are unable to view the form, you may click here to open it in a new window.

We ask that all of our existing patients complete this form, as it will be used to update your child's chart with the most recent demographic information. This is necessary to activate new billing features in existing MyChart accounts, and to grant full MyChart access to new users. MyChart is a portal in which parents are able to view their children's medical and billing records with our clinic. 

 

Our billing policy, updated March 11, 2024, ultimately states that we will be collecting outstanding balances upon checking in for visits, and will be collecting deductible amounts upfront for any Sick, Follow Up, and Consult visits. We ask that you please complete all fields to show your understanding of our new policies. 

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