Forms

PATIENTS CAN REGISTER ONLINE AT:

https://southerntierpeds.myezyaccess.com/Patient/Main.aspx

GENERAL FORMS:

  1. Release-of-Records-Form-02062017
  2. HIPAA Privacy Information Patient Checklist 10262007
  3. NOTICE OF PRIVACY PRACTICES 10262007
  4. Office-Welcome-and-Information-Letter-10262007
  5. Financial Notice 10262007
  6. Patient Rights and Responsibilities 10262007

*****FORMS TO BRING TO APPOINTMENTS*****

Please print, complete, and bring these form(s) to your child’s appointment if your child is being seen for any of the following:

ADHD:

  1. ADHD Vanderbilt Form to be Completed by a Parent
  2. ADHD Vanderbilt Form to be Completed by a Parent in Spanish
  3. ADHD Vanderbilt Form to be Completed by a Teacher
  4. ADHD Vanderbilt Parent FOLLOW UP
  5. ADHD Vanderbilt Teacher FOLLOW UP

Aggression:

  1. Aggression Screening Form

Anxiety:

  1. Anxiety Screening to be Completed by a Parent
  2. Anxiety Screening to be Completed by a Parent in Spanish
  3. Anxiety Screening to be Completed by a Child
  4. Anxiety Screening to be Completed by a Child in Spanish

Autism/Developmental Delays:

  1. Developmental Screening (Please note this form should be completed and brought to ALL 16-30 month Well Child Visits.)

Depression:

  1. Depression Screening for Teens (Please note this form should be completed and brought to ALL Teen Well Child Visits and ALL appointments for Depression.)
  2. Depression Screening for Teens in Spanish
  3. Depression Screening Adults (Please note this form should be completed and brought to ALL 20 year old and over Well Visits and ALL appointments for Depression.)
  4. Depression Screening for Women Who Are Pregnant or Have Recently Given Birth (Please note this form should be completed and brought to ALL Well Baby Visits from Newborn – 1 month old.)

Drug/Alcohol Abuse Screening:

  1. Drug Abuse Screening
  2. Drug and Alcohol Screening (Please note this form should be completed and brought to ALL Well Child Visits starting at 13 years old.)
  3. Drug and Alcohol Screening in Spanish

Eating Attitude Test:

  1. Eating Attitude Test

Obsessive Compulsive Behavior Screening:

  1. Obsessive Compulsive Behavior Screening

PTSD

  1. PTSD Child Symptom Scale