Southern Tier Pediatrics
 
Southern Tier Pediatrics
Practice, P.C.

- 1684 Foote Avenue Extension
Jamestown, NY 14701
Tel: (716) 661-9730
Fax: (716) 661-9732

- One Bank Street
Randolph, NY 14772
Tel: (716) 358-KIDS (5437)
Fax: (716) 358-5438
E-mail: southerntierpediatrics@gmail.com
download forms
Page 1 Office Welcome and Information Letter 10262007.doc
Page 2 Patient information and registration 10262007.doc
Page 3 Patient Information Family History 10262007.doc
Page 4 New York State Department of HealthEligibility Screening Record.doc
Page 5 Release of Records Form 10262007.doc
Page 6 Patient Rights and Responsibilities 10262007.doc
Page 7 Financial Notice 10262007.doc
Page 8 NOTICE OF PRIVACY PRACTICES 10262007.doc
Page 9 Notice of Privacy Practices Acknowledgement Form 10262007.doc
Page 10 HIPAA Privacy Information Patient Checklist 10262007.doc
 
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