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"Are there forms I can complete before my initial visit?" |
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For new patients and existing patients that have information changes In order to expedite the registration process, please fully download, print and complete FORM 1 (Patient Registration), FORM 2 (Privacy Acknowledgement) and FORM 3 (Patient History) from the form list below. If you need to request the release of the patient record of care from a previous provider, complete FORM 4 (Transfer of Record). Please note most physician offices charge a copy/administrative fee to when transferring records to another facility. If you feel there may be an occasion where your child will be brought by a relative, sitter, etc., please complete FORM 5 (Parental Authorization). You may FAX or Mail the completed forms to us or bring them to your initial office visit. Should you have changes to your current information only, please complete FORM 1.
If you have any non-medical questions, send your request to the attention of our Practice Administrator: cpamed@windstream.net FORM 1 FORM 2 FORM 3 FORM 4 FORM 5 For a printable copy of our Privacy Statement: PDF Reader not on your computer? NOTE: Information sent to us via email is being disclosed by you through an unsure manner. Though we are the address recipient, we cannot state subject matter contained in email transitions is 100% protected from unauthorized viewing as required by HIPAA. We, therefore, ask that messages which may contain protected health information that is personal, sensitive and confidential not be remitted to us through email transmissions. |
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Center for Pediatric and Adolescent Medicine, PA 704-799-2878 |
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PRIVACY STATEMENT - OUR STAFF - OUR LOCATION - OFFICE HOURS EMAIL - OUR FAVORITE LINKS - DOSING INFORMATION LINK FORMS - CHOOSING THE RIGHT PEDIATRICIAN |