ONLINE REQUEST FOR NEW PATIENT APPOINTMENT

Thank you for choosing Partners in Pediatrics as your child's medical home, where we always provide a comfortable, caring environment so our patients and their families can feel at ease. Please note that due to the heightened demand during the busy sick season, we typically only accept new patients (not including newborns) from March through September.

Please fill out the survey below with your child's name and the most convenient contact information for us to reach you to schedule your new patient appointment. By completing this survey, you are also authorizing our office to obtain the necessary medical records for transfer.

Please provide your preferred provider choice, as well as a second and third option. We will make every effort to schedule you with your preferred provider if they accept your insurance and have an available appointment. If they are not available, we will schedule you with your next preferred option.

At this time, we are only accepting new patients 12yrs old and younger. 13+ may be accepted with siblings at the provider's discretion.

Please note, this online form does not replace our registration form, which should be completed before your appointment. This form simply allows us to gather as much information as possible to streamline your new patient appointment process. The necessary forms can be accessed on our website or obtained from our offices directly.

Check this box if your request has already been approved by our front office

Patient First Name

Patient Last Name

Date of Birth

Gender

Male Female

Other (Please Specify)

Primary Insurance

Secondary Insurance

Immunizations up to date?

Yes No

You may upload your most recent immunization record if available

Add file

Please upload a file

Date of Last Well Child Check-up

Type of Visit (I.e. 2 month well check vs 4yr well check

You may upload a copy of your last well child check up if available

Add file

Please upload a file

Has this patient ever been seen at Partners in Pediatrics?

Yes No

Primary Family Email address

To receive information about appointments and updates

Primary Phone Number

Other: (Please Specify)

Parent/Legal Guardian #1

Date of Birth

Other: (Please Specify)

Phone Number (Best Contact Number)

Email address

Street Address

City, State

Zip

Driver's License # / State

Parent/Legal Guardian #2

Date of Birth

Other: (Please Specify)

Phone Number (Best Contact Number)

Email address

Street Address

City, State

Zip

Driver's License # / State

Parent Relationship Status

Single Married Separated Divorced Widowed Fostered Other

Is this child adopted?

Yes No

Are there any legal or custody issues that we need to be aware of?

Yes No

Upload legal documents for custody/guardianship If applicable

Add file

Please upload a file

AUTHORIZATION FOR USE & DISCLOSURE OF PROTECTED HEALTH INFORMATION

RELEASE RECORDS FROM:

Previous Health Care Provider

Address (Include City, State & Zip)

Office Phone Number

Office Fax Number

Record Inspection or Information Requested

Complete Medical Records

Immunization Records

Other (Specify):

RELEASE RECORDS TO:

Partners in Pediatrics

8160 Seaton Place, Montgomery, AL 36116

Phone: (334) 272-1799 Fax: (334) 272-4876

Reason for Request

Transferring to Partners in Pediatrics for Continued Care

Patient(s) Name:

Date of Birth

Date of Last Well Child Check-up

Attached additional Names if Necessary

Patient(s) Name #2:

Date of Birth

Date of Last Well Child Check-up

Patient(s) Name #3:

Date of Birth

Date of Last Well Child Check-up

Patient(s) Name #4:

Date of Birth

Date of Last Well Child Check-up

Patient(s) Name #5:

Date of Birth

Date of Last Well Child Check-up

Record Release Authorization

By signing below, I authorize the use and disclosure of my protected health information as requested. I understand the information may be re-disclosed by the recipient and may no longer be protected by the federal HIPAA privacy rule. I have the right to revoke this authorization except to the extent that Partners in Pediatrics has acted in reliance upon this authorization.

**All records will be provided in electronic format unless requested otherwise.**

Indicate Preference:

Electronic Form/Fax

Please Mail to Partners in Pediatics

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application and you are legally authorized to request transfer of records on behalf of the patient listed above.

Printed Name

Relationship to Patient

Phone Number

Please upload Copy of Driver's License & Insurance Card

Add file

Please upload a file

Date Signed

This authorization expires 90 days from the date signed.

Medical records received from your previous doctor are reviewed by your Partners in Pediatrics physician. After review your records will be scanned into an electronic health record created for you. If you would like a copy of your records please notify our medical records coordinator, otherwise they will be shredded for your privacy. Thank you!

Your information will be encrypted.