Before Your First Visit
Before Your First Visit
New Patient Forms
Please print and fill out the following two forms prior to your first visit
- Notice of Privacy Practices (PDF)
Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.
- Authorization for Release of Medical Information (PDF)
Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.
- Authorization and Consent for Treatment (PDF)
All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento
- Preferred Contacts (PDF)
Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos
- Financial Policy (PDF)
This form advises patients of their financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.
Patient Visit Checklist
In order to provide the most efficient and comprehensive care to your child, please ensure you have the following items for all of your child’s appointments:
- NEW PATIENTS – the Intake Form above
- Your child’s health insurance card
- Any necessary referral/authorization number from your Primary Care Physician if required by your insurance plan (please double-check with your particular plan – this must be obtained prior to the visit)
- Any changes to insurance, address, pharmacy, or pediatrician
- All pertinent original x-rays/ CT scans/ imaging scans (not just the report)
- Results from any applicable diagnostic tests (hearing test, sleep studies, etc)
- Co-payment (cash, check or Mastercard/Visa credit cards)
Cancellations- please notify us as soon as possible if you need to cancel or change your scheduled appointment. A $50 No Show Charge will be applied to your account if you do not notify us of a cancellation 24 hours prior to the appointment.
