Notice of Privacy Practices As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU (AS A PATIENT OF THIS PRACTICE) MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION.
Office Policies This form is a printable version of our office policies. They may also be accessed online by clicking here.
Parent Delegation Form This form authorizes us to give immunizations or medical care to a minor in the absence of a parent or legal quardian, but in the presence of your designated adult.
Parent's Questionnaire These are standard parent checklists which help us understand your perception of your childÂ´s behavior.
Parental Information This form should be completed prior to your prenatal interview. It includes all vital information regarding your pregnancy and informs us of any expected health problems.
Records Release Authorization This form authorizes another medical institution or doctor’s office to forward your childÂ´s medical records to our practice.
Teacher Questionnaire These are standard teacher behavioral checklists used by the school system to assess your childÂ´s behavior while in the classroom.
Tuberculosis Risk Assessment This is another simple questionnaire assessing your childÂ´s risk of tuberculosis exposure. It is usually completed prior to the 12 month and five year visit.
Vaccination Consent Form For FluMist, Influenza Virus Vaccine, Intranasal FluMist should only be administered to children and adolescents 5-17 years old and adults 18-49 years old who are healthy. Certain people must not receive FluMist. You must answer each question on this form, and have the answers reviewed by the health care professional to ensure you are eligible to receive FluMist. The health care professional will keep the questionnaire, and any information collected in a confidential manner.