| ADD/ADHD
(Vanderbilt Forms) |
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Initial
Evaluation: ADHD Parent Assessment
Form 1 of 2
Parents should print and complete this form prior to your child's appointment for
evaluation of ADD/ADHD. Please bring both completed forms to your appointment.
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Initial
Evaluation: ADHD Teacher Assessment
Form 2 of 2
Parents should print and have your child's teacher complete this form prior to your
child's appointment for evaluation of ADHD. Please bring both completed forms to your
appointment.
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ADHD
Parent Follow Up Form
Form 1 of 2
Complete these forms only if your pediatrician requests them for a follow up visit.
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ADHD
Teacher Follow Up Form
Form 2 of 2
Complete these forms only if your pediatrician requests them for a follow up visit.
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ADD - ADHD Medication Monitoring Policy
This form will be provided to you at the time of prescription refill for ADD - ADHD
medication(s). This states our policy regarding follow up and monitoring of your child's
status, based on medical industry and health insurance quality care standards.
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| Asthma
Education |
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Asthma
Questionnaire
This form is used to assess your child's level of asthma. Please complete it before your
next appointment and ask the office staff to place it in your child's chart. The
pediatrician or nurse practitioner will review the questionnaire with you.
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| Billing |
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Billing Guidelines
This form contains a representative list of potential fees and charges you may incur, so
you are better informed at the time of service, and prior to the arrival of a billing
statement.
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Medical Records Copying & Shipping Policy
If you need a copy of your child's medical records for any reason, please review and
complete this form and turn it in at your pediatrician's office.
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| Established Patients |
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30-Month Visit Questionnaire
Please complete this form and bring it with you to your child's 30-month (2.5 year) well
visit. |
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Change
of Insurance or Address
Please complete this form if you have a change of address or change of insurance and bring
it with you to your next appointment.
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Records Release FROM Pediatric Health Care Alliance
Please fill out this form to have your child's medical records released FROM Pediatric
Health Care Alliance to a different pediatrician.
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Patient Registration
If you are a current patient, you will be asked to complete a new registration form each
year. This form is updated for 2010, and only needs to be submitted once for the year.
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Permission
to Treat - Update
If there are any changes to the individuals who have your permission to bring your
child(ren) into the office for care, please complete this form.
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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.
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Screening Questionnaire for Child
& Teen Immunizations
Please bring this completed form to any "vaccine-only" visit. |
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What You Should Know About Electronic Medical Records (EMR)
This is a handout for all Alliance patients. We will be implementing EMR at all of our
offices over the next 2 years, and this handout includes information on changes and
improvements to our services. This form does not require a signature, it is for
informational purposes only.
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| New
Patients |
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Patient Registration
If you are a new patient, please complete this form and bring it with you to your first
appointment.
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Records Release TO Pediatric Health Care Alliance
Please complete this form so that your child's medical records can be released TO your new
Pediatric Health Care Alliance pediatrician, from your previous medical provider.
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Permission
to Treat
Please complete this form to notify us as to the individuals who may bring your child to
the office for treatment. Without this form, we will be unable able to deliver medical
service to your child if he or she is accompanied by someone other than the listed
parent(s)/legal guardian.
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Patient
- Family History Form
Printing and filling out this form at home will save you additional time in our office
before your visit.
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Billing Guidelines
This form contains a representative list of potential fees and charges you may incur, so
you are better informed at the time of service, and prior to the arrival of a billing
statement.
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Privacy Notice
If you are a new patient, we will ask you to read and sign a Privacy Notice. To save you
time in the office, please read and sign this document. Bring only the signed last page
with you to your appointment.
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| Physicals |
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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.
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Adolescent Patient Information Form
When our pediatricians see adolescent patients, we request the adolescent complete a short
confidential questionnaire. Please print this form and have your child complete it before
his or her appointment. Your child can give the 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 your office.
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Pre-Participation Physical Evaluation
Please have your child complete this form prior to his or her scheduled sports physical.
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| Vaccines |
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Thimerosal
and the Flu Vaccine
If your child is scheduled to receive the flu vaccine, you will be asked to read this
information about thimerosal. Thimerosal is used in some multi-dose vials of vaccines as a
preservative to prevent contamination.
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Influenza
Authorization
Please complete this form to authorize the Alliance to administer the influenza vaccine to
your child. Prior to signing this form, you will need to read the Vaccine
Information Statement from the Centers for Disease Control and Prevention.
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FluMist
Questionnaire
If your child is age 2 years or older, he or she may be eligible to receive the intranasal
flu vaccine, FluMist. If you would like your child to receive this type of flu vaccine,
please fill out this quesionnaire for review with your pediatrician.
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