Save time for your next visit! Print out forms & fill them out ahead of your next visit.

Forms

What are these forms for?

  • Patient Information Form: Tells us your personal information and health history
  • Authorization to Treat: Gives us permission to treat you
  • Caregiver Communication Form: Tells us who you want involved in your care
  • Records Request Form: Allows us to get your records from a previous provider
  • Prescription History Consent: Allows us to get your medication history
  • Affordable Care Program Application: To apply for reduced fees
Advance Directive Authorizing Consent To Treatment For Child
Advance Directive Authorizing Consent To Treatment For Child
Advance Directive Consent to Treat_Peds.pdf
361.7 KiB
653 Downloads
Details
Affordable Care Program Application
Affordable Care Program Application
ACP Application 2015.pdf
726.7 KiB
1179 Downloads
Details
Authorization to Release Health Information
Authorization to Release Health Information
Release-of-Information-Combined-2016.pdf
247.1 KiB
530 Downloads
Details
Care Management Joint Authorization For Release of Information
Care Management Joint Authorization For Release of Information
Joint Authorization for Release - Care Management.pdf
261.7 KiB
972 Downloads
Details
Caregiver Communication Form
Caregiver Communication Form
Caregiver Communication Form.pdf
376.9 KiB
481 Downloads
Details
Consent To Treatment
Consent To Treatment
ConsenttoTreat.pdf
179.6 KiB
510 Downloads
Details
HealthInfoNet Consent to Share Mental Health & HIV/AIDS Records
205.1 KiB
520 Downloads
Details
HealthInfoNet Opt-In Form
HealthInfoNet Opt-In Form
HIN_Opt-In_Form.pdf
252.6 KiB
477 Downloads
Details
HealthInfoNet Opt-Out Form
HealthInfoNet Opt-Out Form
HIN_Opt-Out_form.pdf
469.4 KiB
821 Downloads
Details
New Pediatric Patient Medical History
New Pediatric Patient Medical History
New Pediatric Patient Medical History.pdf
301.2 KiB
1004 Downloads
Details
Newborn Medical History
Newborn Medical History
Newborn Medical History.pdf
210.1 KiB
570 Downloads
Details
Pediatrics Patient Information Form
Pediatrics Patient Information Form
Pediatric Patient Information.pdf
174.2 KiB
612 Downloads
Details
UDS Form
UDS Form
Current UDS Form 7-9-13.pdf
11.0 KiB
430 Downloads
Details
Who Can We Talk to About Your Care?
Who Can We Talk to About Your Care?
Caregiver Communication.pdf
376.9 KiB
445 Downloads
Details

Documents

eHealth Patient Portal
eHealth Patient Portal
eHealthPatientPortal-Pediatric-Insert-2015.pdf
883.7 KiB
1094 Downloads
Details
Goodbye Letter
Goodbye Letter » Post
goodbye-letter.pdf
58.8 KiB
244 Downloads
Details
Health Info Net
Health Info Net
HIN_1page_color.pdf
534.4 KiB
490 Downloads
Details
Immunization Schedule — 0 to 6 years
Immunization Schedule — 0 to 6 years
parent-ver-sch-0-6yrs_2015.pdf
321.3 KiB
793 Downloads
Details
Immunization Schedule — 7 to 18 years
Immunization Schedule — 7 to 18 years
parent-version-schedule-7-18yrs_2015.pdf
629.7 KiB
829 Downloads
Details
Newborn Booklet
Newborn Booklet
Newborn Booklet - HHHC.pdf
2.5 MiB
859 Downloads
Details
Newborn Booklet
Newborn Booklet
Newborn Booklet 2014 - PRINT.pdf
2.4 MiB
937 Downloads
Details
Welcome Letter
Welcome Letter
Welcome sheet.docx
17.1 KiB
603 Downloads
Details
Well-Child Exam Schedule
Well-Child Exam Schedule
PEDS well-child exam.pdf
585.0 KiB
557 Downloads
Details