Patient Registration Forms

We are happy to provide our office forms for convenient download on your home computer for you. Please print and complete the forms below and bring them with you to your child's first appointment. Please call our office and our courteous staff will assist you if you have any questions in preparing for your child's first visit.

New Patient Registration - English (Online)

New Patient Registration - Spanish (Online)

School Forms

• School Forms (3231/3300)
If your child needs forms for school to document immunizations or hearing/vision screening, just let us know. We are happy to provide these to you at your child’s Wellness Check visits. If it is by request, please give us one business day to process this paperwork.

• Sports Physical/Camp Forms
Please bring forms to your Wellness Check appointment and please note that the parent/student sections are to be completed before the physician signs the forms. Completed forms will be returned to parent or patient only; we are no longer able to fax paperwork to schools. If forms are requested at a later day from the day of your child's Wellness Check, it might incur in charge; please call the office for details.

Forms for Services

Forms for Services (Katie Beckett, FMLA, SSI, etc.)

Some families require forms that require more detail. Examples of these are such things as Prior Authorization Forms for prescriptions, Katie Beckett Forms, Disability claims, Family Leave requests, to name a few. Because of the need to review your child’s individual history for such paperwork, they require a bit more advance notice and some forms may require a charge. Our staff will provide you a time frame for expected completion when you call with your request, and will notify you of any charges if there are any.

Medical Records Request Forms

In order to protect the privacy of our patients, we require written authorization to release your child’s medical record. You must complete a Medical Records Request Form.

There is no charge to send medical records between physicians however, there is a fee associated with other medical records requests, please call our office to get details.

Medical Records Request - English (pdf)

Medical Records Request - Spanish (pdf)

Medical Records Request - English (online)

Medical Records Request - Spanish (online)

Non-Parent Consent Forms

For those occasions when you may not be able to bring your child to their medical visits, and you assign someone else to bring him/her please complete the following form and return it to our office before your child’s visit.

Non-Parent Consent - English (PDF)

Non-Parent Consent - Spanish (pdf)

Non-Parent Consent - English (online)

Non-Parent Consent - Spanish (online)

Privacy Statement

We want to provide the best care we can in the most cost-efficient manner to help you get the most from your insurance benefits. Please work with us by providing timely and accurate information. If you know there is going to be an issue please let us know up front so we can work with you.

For your convenience we accept most major insurances including:

Anthem (BCBS)
Humana (we do not accept HMO X))
United Healthcare

For all patients on plans in which we are participating providers:

• Please consult with your insurance company member services department regarding your specific benefits and coverage. We DO NOT know the specifics of what your specific insurance policy covers, and you should understand the details of the plan you have selected. There could be numerous benefits and cost variations your employer has chosen. There are literally dozens of different plans from BCBS, United, Aetna, Cigna, and other smaller insurance networks.

• Our office will gladly file your insurance; however, our relationship is with you and not your carrier

• Please bring your current insurance card to every visit. Without current insurance information, there is no way for us to verify eligibility and file your claim. So unfortunately, when you do not provide us with this important information, you will be considered as a self-pay on the day of service.

• Your copay and/or deductible amount will be due at the time of service

• The parent/guardian whose names are listed in the Patient Registration Form are responsible for all charges incurred in your child's care and treatment.

• It is your responsibility to clear your balance before your due date on your bill or if you have a visit before that, whichever comes first. We accept Visa, Master Card, American Express, Discover for your convenience.

• For your convenience you may pay your bill online - Click Here

For further information please review our financial policy included in our Patient Registration Forms