All of our forms are attached as PDF documents. Click on the link to open and print any form.
New Patient Forms
New Patients are required to fill out several forms. Learn more about our New Patient policies and forms.
Medical Records Request
If your child was followed by another pediatrician before coming to our practice, it is important to get your child’s prior medical records in order for us to provide the best possible care. To request medical records from another pediatrician or practice, please complete this form and either mail or fax it to your child’s previous pediatrician. This authorization allows us to obtain your child’s prior medical records, including growth curves and immunizations.
Request to Transfer / Copy / Inspect Medical Records
If you are leaving our practice and would like us to send a copy of your child’s medical records to your new pediatrician, obtain a copy of your child’s medical records, or review your child’s chart, please complete this form and mail or fax it to South East Bay Pediatrics.
Please allow 2 weeks from the time we receive the form to process the request. If you are requesting to review your child’s chart, we will be contacting you to make appropriate arrangements.
Please note there is a fee of $25 to send your child’s medical records to your new pediatrician.
Authorization to Fax and Disclose Protected Health Information
If you are requesting us to fax and disclose any Protected Health Information to a third party, HIPAA laws require us to have a signed consent and authorization. For example: immunization records, medication forms, or school forms faxed directly to the school. The following form needs to be filled and signed before we can send any information to a third party.
Update Contact and Insurance Information
To update your contact information, please complete and return this form.
Health History Questionnaire
The Health History Questionnaire is as general questionnaire that we ask all our new patients. It gives us a snapshot of your child’s medical, developmental, and social history. This questionnaire is required at your child’s first visit to our office. Please have this filled to the best of your abilities and bring the completed form at your first appointment.
Vaccine Designee Consent Form
The Vaccine Designee Consent Form allows you as a parent to designate another adult (for example, a grandparent or other relative) to sign for vaccinations if you are not present during your child’s visit. Please note that this does not apply to one-time only vaccinations (e.g. travel vaccines), the first vaccine in any given series, and if your child has never received this vaccine before. It is important that you as a parent are present if this is the first time your child is receiving a particular vaccine in order for us to adequately discuss the indications and risks of the vaccine and answer any questions you may have.
The Vaccine Designee Consent Form needs to be brought to our office at the time of your child’s visit when the vaccinations are to be given.
Consent for Treatment by Designated Guardian Form
Per the Federal Trade Commission (FTC) effective August 1, 2009, businesses, including physician practices, will be required to implement identity theft prevention measures. At South East Bay Pediatrics these measures include:
- Identity verification will be required at the time patients are checked into the office. Parents and/or legal guardians bringing patients in for an appointment will need to present a photo identification in order to be registered.
- If parents are unable to bring their children in for an appointment and instead designate another adult (over 18 years of age) to serve as the child’s guardian during the appointment, parents are required to bring a signed Consent for Treatment by Designated Guardian form at the time of the visit. The designated guardian will need to bring appropriate photo identification for verification.
We understand that forms and paperwork are becoming an increasing burden to our families. However, we all need to adhere to state and federal regulations in order to continue serving our families. Thank you very much for your understanding.
Patients 18 Years and Above
When a patient turns 18 years of age, privacy laws come into effect. Even though an adult patient is still being insured under his/her parents’ insurance, we are not permitted to discuss any aspect of the patient’s care without expressed written consent from the patient detailing what portions of his/her case we may discuss. This includes release of any information involving issues that were addressed even before the 18th birthday. If an 18 year old wishes to allow his/her physician to discuss portions of his/her care to a parent or other person directly involved in his/her healthcare, the following consent form needs to be signed:
ADHD & ADD Forms
NOTE: Please contact our office to receive copies of all ADHD forms and questionnaires
- ADHD Parent Packet Overview — parents can fill these out together
- ADHD Parent Packet Questionnaire — each parent should fill this out individually
- ADHD Teacher/Counselor Packet — to be given to teachers (and/or a counselor) who works with your child directly in the school setting