Forms

• Consent for Treatment
• HIPAA Privacy Practices Acknowledgement Form
• HIPAA Notice Of Privacy Practices
• Patient Demographics Form
• Records Release - Transfer In

Forms. Ya gotta love 'em. We are happy to complete your child's form, but please understand we are asked to complete a zillion of them, usually between June and August, and they do take time to process.

We Don't "Just Sign" Forms
Our nursing team reviews your child's medical record and completes part of the form. Next, one of our doctors or nurse practitioners reviews your child's medical record, determines whether your child is healthy enough to be able to participate in the desired activity, completes the remainder of the form, and then signs it.

Best Time to Get Your Form Completed? At Your Well Child Check.
We are happy to complete your child's School/Daycare/Camp form free of charge at your well child visit. If you think your child may be interested in playing sports, please bring a Sports Form to the physical. Be sure to complete your portion of the form first.

Not up to date on your Well Child Check? Call us to schedule!
If you need a form completed and your child is not up to date on his/her physical, you will need to schedule the physical. We will complete the form at that time.

Between Well Child Checks?
If you need a form completed  and your child is not due for his/her physical, we are happy to do that too. To streamline the process for you, please follow these steps:

• Complete your portion of the form.
• Provide us with the form, your payment, and desired pickup date. (The form can be uploaded to your portal account, My Kid's Chart, or FAXed, or dropped off at our office.

We will upload the form to your portal account, My Kid's Chart and notify you that the form is complete.

PIAA Forms
In addition to a current well child exam, PIAA Forms also require a current (within the past year) vision screen. If your child had a vision screening done at another office, please ask that office to send us the results so we can complete the PIAA.


TIMEFRAMES AND FEES

PIAA Forms:
$15 - 7 to 10 business days
$20 - 2 to 6 business days
$25 - Next day by 5pm
NO SAME DAY SERVICE

CAMP | SCHOOL | SCOUT | DAYCARE Forms:
$5 - 7 to 10 business days
$10 - 2 to 6 business days
$15 - Next day by 5pm
NO SAME DAY SERVICE

• PA State Health School Form
• PIAA Form
• Child Health Report/Daycare

• 14yr Consent Form
• Drivers Permit Form
• Transition Intro Letter
• Transition Questionnaire

• Vanderbilt Initial Assessment - Parent
• Vanderbilt Initial Assessment - Teacher
• Vanderbilt Follow Up - Parent
• Vanderbilt Follow Up - Teacher