Downloadable Forms

New Patient Website Packet
Packet of New Patient Information Forms that includes:

  • Patient / Family Information Form;
  • HIPAA / Insurance / Acknowledgement;
  • Medical History;
  • Financial Policy;
  • Credit Card on File Form;
  • Transfer Request

Medical Records Transfer In
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.

This form is also required any time information is requested to be released from a patient’s chart.  Simply check the box indicated for “not transferring out.”

Authorization for Health Care of Minor Child
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

Sports-Questionnaire – To be completed when requesting forms for all camp/athletic activities.

2019 Scholarship Deadline Date:  CLOSED

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.

2019 Scholarship Application