"Are there forms I can complete prior to my initial visit?"

 
   

Forms

 
     
 

In order to expedite the registration process, please fully download, print and complete.

Please remember to bring your insurance card and proper form of ID with you.

For new patients and existing patients that have information changes:

FORM 1 (Patient Registration), FORM 2 (Privacy Acknowledgement) and FORM 3 (Patient History)

If you need to request the release of the patient record of care from a previous provider:

FORM 4 (Transfer of Record)
PLEASE NOTE: most physician offices will charge a copy/administrative fee directly to you when transferring

 records to another facility/provider. You may want to contact previous providers to discuss potential cost.

If you feel there may be an occasion where your child will be brought by a relative, sitter, etc:
FORM 5 (Parental Authorization)
.

 

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FORM 1 FORM 2 FORM 3 FORM 4 FORM 5

You may FAX or Mail the completed forms to us or bring them to your initial office visit.

Should you have changes to your current information only, please complete FORM 1.
Please bring any new/updated insurance cards or information with you.

For a printable copy of our Privacy Statement:

HIPAA

If you have any non-medical questions, send your request to the attention of our

Practice Administrator: cpamed@windstream.net
Please note: This email address is not constantly monitored (checked approx monthly)

NOTE: Information sent to us via email is being disclosed by you through an unsure manner.

Though we are the address recipient, we cannot state subject matter contained in email

transitions is 100% protected from unauthorized viewing as required by HIPAA.

We, therefore, ask that messages which may contain protected health information that

is personal, sensitive and confidential not be remitted to us through email transmissions.

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WE APPRECIATE YOUR TRUST IN

CARING FOR YOUR CHILDREN!!!

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Center for Pediatric and Adolescent Medicine, PA
136 Gateway Boulevard - Suite A
Mooresville, NC 28117-5608

Fax: 704-799-1627

704-799-2878

VACCINATION STATEMENT  -  OUR STAFF  -  OUR LOCATION  -  OFFICE HOURS  -  HOSPITAL STATUS

FORMS  -  COPY FEE  -  EMAIL  -  PRIVACY STATEMENT  -  CHOOSING THE RIGHT PEDIATRICIAN