Patient Information Forms
Packet of New Patient Information Forms that includes: Patient / Family Information Form; HIPAA / Insurance / Acknowledgement; Medical History; Financial Policy; Credit Card on File Form
This form will allow us to request and obtain medical records from your previous physician(s). Please be sure to include the fax number.
Medical Records Transfer Out
Use this form if you are leaving Parker Pediatrics as a patient and need to transfer your child’s care to a new medical provider.
Care authorization letter to be completed by parents needing to authorize other people – grandparent, step parent, family friend, nanny, etc., to bring child(ren)to medical appointments.
Authorization for ROI Adult Patient
Form to be completed by patient (18 and older) giving permission to discuss or release protected health information pertaining to them to designated people
This form is required before all Sport, Camp, Boy/Girl Scout forms, or any other form that requires a physician’s signature to certify clearance for participation. Please submit with all form requests.
2018 Scholarship Deadline Date: 05/04/2018
Each year Parker Pediatrics & Adolescents awards two scholarships to graduating seniors who plan to go into the healthcare field. Any high school graduating senior who is, or has been, a patient of ours may apply by completing and submitting an application by the deadline date shown above.
Completed forms can be returned to Parker Pediatrics & Adolescents via mail, fax, or hand delivery to the office on or before the deadline.