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First Visit/Patient Forms

Welcome to our office!  We are pleased to welcome you and your child(ren) to our practice.  Our goal is to offer the very best care to our patients and families.
 
We request that you complete our Registration Form prior to your first visit to expedite your check-in process.  In addition, if you feel it appropriate, the Alternate Care Authorization form allows you to designate individuals whom you allow to bring your child to the office, such as a grandparent, daycare provider, etc.  You may also wish to complete the Medical Records Release Form if you are transferring care from another office or hospital.
 
In addition, we will ask you to sign three policies at your first visit and at periodic intervals thereafter:  Notice of Privacy Practices (or HIPAA), Financial Policy & Consent to Treat, and the Universal Authorization.  These are all standard forms – should you have any questions, the registration clerk can discuss them with you during the check-in process.  
 
In the future, if the need arises and you have a change of address, please either notify us through the Patient Portal of your move, or complete and mail in the Change of Address Form.
 
For your child’s safety and per government regulations, we require that you present your photo ID and current insurance card at each appointment and be prepared to pay any applicable copayments and past due balances applicable to your visit.
 
Thank you!
Priority Care Pediatrics, LLC Providers and Staff

Please Complete

Registration FormRegistration Form

Optional

Alternate Care AuthorizationAlternate Care Authorization

Optional

Medical Record Release FormMedical Record Release Form

When Needed

Change of AddressChange of Address

Please Review

Notice of Privacy PracticesNotice of Privacy Practices

Please Review

Financial Policy and ConsentFinancial Policy and Consent

Please Review

Universal AuthorizationUniversal Authorization

When Needed

Psychiatry ReferralPsychiatry Referral