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 12 yrs 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

Number of Children for Appointments Max 5 per New Patient Request

1 2 3 4 5

Patient First Name

Patient Last Name

Date of Birth

Gender

Male Female

Other (Please Specify)

SSN

Primary Insurance Carrier

Primary Insurance Contract/ID Number

Secondary Insurance

Secondary Insurance Contract/ID Number

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 Needed (i.e. 2 month well check, 4yr well check, etc.)

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

Multiple Birth?

Yes No

If yes, Birth Order:

Is this child adopted?

Yes No

New Patient #2

Patient First Name

Patient Last Name

Date of Birth

Gender

Male Female

SSN

Primary Insurance Carrier

Primary Insurance Contract/ID Number

Secondary Insurance

Secondary Insurance Contract/ID Number

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 Needed (i.e. 2 month well check, 4yr well check, etc.)

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

Multiple Birth?

Yes No

If yes, Birth Order:

Is this child adopted?

Yes No

New Patient #3

Patient First Name

Patient Last Name

Date of Birth

Gender

Male Female

SSN

Primary Insurance Carrier

Primary Insurance Contract/ID Number

Secondary Insurance

Secondary Insurance Contract/ID Number

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 Needed (i.e. 2 month well check, 4yr well check, etc.)

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

Multiple Birth?

Yes No

If yes, Birth Order:

Is this child adopted?

Yes No

New Patient #4

Patient First Name

Patient Last Name

Date of Birth

Gender

Male Female

SSN

Primary Insurance Carrier

Primary Insurance Contract/ID Number

Secondary Insurance

Secondary Insurance Contract/ID Number

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 Needed (i.e. 2 month well check, 4yr well check, etc.)

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

Multiple Birth?

Yes No

If yes, Birth Order:

Is this child adopted?

Yes No

New Patient #5

Patient First Name

Patient Last Name

Date of Birth

Gender

Male Female

SSN

Primary Insurance Carrier

Primary Insurance Contract/ID Number

Secondary Insurance

Secondary Insurance Contract/ID Number

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 Needed (i.e. 2 month well check, 4yr well check, etc.)

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

Multiple Birth?

Yes No

If yes, Birth Order:

Is this child adopted?

Yes No

Primary Family Email address

To receive information about appointments and updates

Primary Phone Number

Other: (Please Specify)

Parent Relationship Status

Single Married Separated Divorced Widow Foster Other

Other: Please Specify

Is there a legal or custody arrangement in place for the child(ren)? (i.e., Divorce, Joint Custody Arrangement, etc.)

Yes No

Upload legal documents for custody/guardianship.

Add file

Please upload a file

Is the child currently in a Safety Plan or in DHR Custody/Placement?

Yes No

Upload legal documents/safety plan/placement letter.

Add file

Please upload a file

DHR County

DHR Caseworker Name

DHR Caseworker Number

Parent/Legal Guardian #1 (Primary)

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

AUTHORIZATION FOR USE & DISCLOSURE OF PROTECTED HEALTH INFORMATION

RELEASE RECORDS FROM:

Previous Health Care Provider

Street Address

City, State

Office Phone Number

Office Fax Number

Record Inspection or Information Requested Please release all records unless otherwise specified.

Complete Medical Records

Immunization Records

Other

Other (Specify):

RELEASE RECORDS TO:

Partners in Pediatrics

8160 Seaton Place, Montgomery, AL 36116

Phone: (334) 272-1799 Fax: 334-888-8708

Reason for Request

Transferring to Partners in Pediatrics for Continued Care

Release Records for the Following Patients:

Patient(s) Name:

Date of Birth

Date of Last Well Child Check-up

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 Preferred

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(s) listed above.

Printed Name

Person Filling Out This Request

Relationship to Patient

Phone Number

Please upload image of Driver's License (Front & Back)

Add file

Please upload a file

Date Signed

Please upload image of Insurance Card (Front & Back)

Add file

Please upload a file

This authorization is valid for up to 365 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. Thank you!

Your information will be encrypted.