Forms

Authorization Form: This signed authorization form is required any time you wish us to fax or mail any part of your child’s medical records directly to a third party. It is also required in order to request a full set of medical records when leaving our practice. We will provide one free copy of your child’s full medical records; additional copies incur a charge of $10.

MyChart Adult Proxy Access Consent Form: This form grants proxy access to parents or guardians of adult (over 18) patients. Both patient and parent/guardian must sign.

Food Allergy Action Plan: Fill this out if your child needs an allergy action plan for school and bring to your next visit. Be sure to check off the appropriate box(es) for symptoms, and complete the medications section.

Vaccine Policy: We require all patients to adhere to recommended immunization schedules. This notice outlines our policy.

Financial Policy: This notice outlines our payment policies and your responsibilities with regard to health insurance.

Confidentiality Policy: This notice describes how we approach confidentiality with teenage patients.

Notice of Privacy Practices: This notice describes how medical information about your child may be used and disclosed, and how to access this information.