We are the one place you can bring your child
for all of your child's medical needs.
Your Child's Medical Home™
For foster parents (patients of any age): this form must be completed by the guardian who will be present for office visits.
For patients 18 years and older: this form must be completed by the patient.
Please fill out this form to allow your parents or anyone else that you have identified access to your medical information.
This registration form is for patients 18 years and older or foster parents and is required each year to obtain current information for patients and parents.
For your convenience, we offer a service to keep your credit card on file for any charges related to office visits and outstanding balances. Please complete this form and bring it to the office at your next visit if you would like to opt-in to this service.
Our complete notice is available for your review. A parent/guardian will be asked to sign off on receipt of this notice at the first visit each year. Patients ages 18 years and older will be asked to sign off on receipt of this notice at the first visit after they reach legal age.
This form contains detailed billing policies and a representative list of items with potential fees and charges, to ensure you are better informed at the time of services and prior to the arrival of a billing statement. A completed form is required each year.
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 provide medical care to your child if they are not accompanied by the parent(s)/legal guardian listed on the Patient Registration Form.
Please fill out this form to have your child's medical records released FROM Pediatric Health Care Alliance to another doctor or medical facility.
For patients ages newborn to 17 years old: This form must be completed by the parent or guardian who will be present for office visits. It covers our financial responsibility policies and notice of privacy practices.
A registration form is required each year to ensure current information is on file.