patient portal


Patient Forms

In an effort to save you time, we have provided several forms to help you prepare for your office visit. Please complete the form (or forms) that best represents your upcoming appointment and bring it with you to help reduce your waiting time.

Please remember to also bring your most current insurance card to each visit to ensure the information (group, provider number, etc.) is valid at the time of service. Incorrect or out-of-date information will delay your claim, and you may be held responsible for the full payment of the claim.

Your insurance card is similar to a credit card – the information must be valid in order for it to be used. If we do not have the most up-to-date insurance information, it makes it difficult to process the claims.

Adobe Acrobat Reader is required to view the following forms. To download this free, click here.


ADHD Vanderbilt Assessment Forms

For Parents

For Teachers


Established Patients

Change of Insurance or Address
Please complete this form if you have a change of insurance and bring it with you to your next appointment.

Patient Registration
If you are a current patient, you will be asked to complete a new form each year. If you haven’t already, please complete this form for the current year and bring it with you to your next appointment.

Authorization/Consent for Treatment
If there are any changes to the individuals who have your permission to bring your child(ren) to the office for care, please complete this form.

Privacy Notice
If you have not read and signed a Privacy Notice for your child(ren), please read and sign this document. Bring only the signed last page with you to your appointment.

Rx Pickup Authorization Form

Vaccine Policy

Permission to Fax

Non-Covered Services Authorization


New Patients

Patient Registration
If you are a new patient, please complete this form and bring it with you to your first appointment.

Authorization/Consent for Treatment
Please complete this form to notify us as to the individuals who may bring your child(ren) to the office for treatment. Without this form, we will be unable to deliver medical service to your child(ren) if he or she is accompanied by someone other than the listed parent(s)/legal guardian.

Privacy Notice
If you are a new patient, we will ask you to read and sign a Privacy Notice. To say you time in the office, please read and sign this document. Bring only the signed last page with you to your appointment.

Financial Policy

Pediatric History Form

Physicals

Adolescent Form for Parents
If your adolescent child has an appointment with one of our pediatricians, please print and complete this form. Your child will also need to complete the “patient adolescent form” listed below.

Adolescent Patient Information Form
When our pediatricians see adolescent patients, we request the adolescent a short confidential questionnaire. Please print this form and have your child complete it before his or her appointment. Your child can give this form directly to the pediatrician to protect his or her feeling of confidentiality. If you have any questions regarding this form, please do not hesitate to contact our office.

Pre-Participation Physical Evaluation
Please have your child complete this form prior to his or her scheduled sports physicals.

Medical Records Transfer Forms

Transferring to Northwest Pediatrics
If you are wanting to transfer your child(rens) medical care to Northwest Pediatrics, please complete this form. You can fax/mail it directly to your current pediatrician or physician or you can bring it with you to your first appointment and we will fax it for you.

Transferring out
If you are moving out of the area and need to transfer your child(rens) medical records, please use this form. Please note, there is a fee to transfer medical records.

 

 


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