Please complete and submit these HIPPA compliant forms prior to your child/children’s well visit each year
Wavier for Vision Testing (Ages 1 and 2) (Does not apply to patients with Husky insurance)
Wavier for Hearing and Vision testing (Ages 3 and older) (Does not apply to patients with Husky insurance)
Teen Discussion/CHADIS waiver (Ages 13-17)
Waiver for non-covered services Use this form to agree to services provided in our office for baseline screening EKGs and ImPACT concussion testing.
Acknowledgement of Financial Policy.
Click here to review Financial policy
Acknowledgement of Receipt of Notice of Privacy Practices
Click here to review Notice of Privacy Practices
Upload a copy of your insurance card
Complete this form if you need to update any demographic or insurance information (eg. address, email address, insurance information)
Waiver to speak to parents/guardians of patients 18y and older
Waiver for portal access for parents/guardians of patients 18y and older