patient forms

CLINICAL INFORMATION

Dosage Chart for Tylenol & Motrin/Advil (PDF)

M-Chat - Modified Checklist for Autism in Toddlers (PDF)

ADHD Rating Scale (PDF)

 

BUSINESS FORMS

Patient Registration Packet includes all 3 (Demo, Financial Policy & Authorization form) (PDF)

Financial Policy (PDF)

Privacy Policy (PDF)

Medical Records (PHI) Request Form- Existing patients of our practice who are requesting copies of Medical Records/ Protected Health Information complete this form.

Request and Authorization for Medical Records/Protected Health Information – New patients who would like to transfer medical records from your previous physician’s office, use this form, use this form for Richmond Ave location

Request and Authorization for Medical Records/Protected Health Information – New patients who would like to transfer medical records from your previous physician's office, use this form for Hylan Blvd location

Credit card and ACH Authorization form (PDF)

Financial Policy Addendum (PDF)

Financial Policy for GHI/Emblem patients (PDF)