New Patient Information

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Before the Initial Visit

The first visit to the office requires a lot of administrative time. Records from previous pediatricians, immunization records, insurance information and patient information sheets must be reviewed. Please arrive 15 minutes earlier than your scheduled time to allow for this process. Forms can be downloaded and signed in advance. 

• Demographics: Patients can pre-register their child’s demographics via the Patient Portal but the Patient Information Form needs to be completed. Any future changes can be made directly on the Patient Portal. For your convenience, the Patient Information Form on line is fillable and can be printed.  

• Preferred pharmacy: Please provide us with a preferred pharmacy. This can be changed at any time on the Patient Portal or at the visit check-in. E-prescribing will be required for all New York State prescriptions effective March 27, 2015.  
   

• Consent forms: Federal laws require us to provide assurance of privacy and to attest that we will keep your personal and medical information confidential. We need to give you information about our privacy practices, financial policies and have your consent to use e-mail. You must sign to confirm that you have received that information. These forms must be signed once prior to the examination. This can be done in advance on the Patient Portal, by downloading the forms or at the initial visit check-in.  
   
• Transfer of medical records: It is very helpful for the Provider to have reviewed previous medical records prior to the initial visit. Please download the Medical Record Request, sign and send to the previous pediatrician. Please allow enough time for the records to be received and processed by our office.  
   
• Family History Form: For our records, we need to understand your family’s medical history. This form can be downloaded, completed and given to the staff on the first visit or can be completed on the Patient Portal, under Questionnaires, Medical History.  

If the first visit is a Newborn Visit, recently discharged from the Newborn Nursery, please bring all records; immunization card, hearing test results, metabolic screen receipt and discharge summary. 

At Each Visit

• Current insurance card: at each visit, please bring your current insurance card. The receptionist may need to verify your eligibility.  
   
• School/camp forms: please remember to bring all school and camp forms. Please write your child’s name and date of birth on every page of the forms. Please indicate on the forms any allergies, dietary restrictions and medications that you feel the school or camp needs to be aware of.  
   
• Review and update demographics: your child’s information needs to be reviewed annually to insure that we have all of the proper contact information. This can be done securely on the Patient Portal or at the visit check-in. It is very important that we have accurate address and home/cell phone numbers.  

Download Forms

• • New Patients – Medical Record Request Form: Please download, sign, and send to your CURRENT pediatrician. Please allow enough time for the records to be received and processed by our office. (attached NYS release form)
    • Medical Record Request Form
  • Existing Patients – Medical Record Release Form: Please download, sign, and send to our office and allow up to 7-10 business days for processing.
    • Medical Record Release Form

  • M-CHAT: The M-CHAT is administered as part of the 18-month old and 24-month Well Child Visits to help screen for developmental problems.
    • M-CHAT
  • Vanderbilt Forms: If requested by your Provider as part of ADHD management.
    • Vanderbilt Assessment Scale – Parent Informant
    • Vanderbilt Assessment Scale – Parent Follow-up
    • Vanderbilt Assessment Scale – Teacher Informant
    • Vanderbilt Assessment Scale – Teacher Follow-up