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Please review these forms and policies.

Each form provided here can be printed and filled out at your convenience.

 

Registration Forms

 

Please fill out each form completely, including all information requested, before arriving to our office. All information requested on the form is an important part of providing the best possible care for your child. When you arrive for your appointment, our front office will ask you to provide us with your insurance card and driver’s license so we may obtain a copy for our file. You are required to update your information every six (6) months. Each form should be read carefully before signing. If there is anything you have a question about, please feel free to contact our office at 334-272-1799 or just ask when you arrive.

Registration Form

Patient Questionaire

HIPAA Consent Form

 

Well Check Visit Schedule

 

The physicians of Partners in Pediatrics recommend an age appropriate well check visit. This well check visit schedule should be used only as a general guide. Your physician may recommend other services as needed.

Checkup Schedule

 

Immunization Schedule

It is the policy of Partners in Pediatrics, LLC to follow the immunization schedule recommended  by the Center for Disease Control and Prevention and the American Academy of Pediatrics. Please see the schedule below for further details concerning immunizations.

Immunization Schedule Age 0 to 6

Immunization Catchup Schedule

Immunization Schedule Age 7 to18

 

 

Acetaminophen Dosing Schedule

 

Recently the dosage changed for acetaminophen & ibuprofen. Please see the attachment below for the new dosage schedule for determining the proper dose when administrating acetaminophen. As always please call our office if you have any questions or concerns.

Acetaminophen Dosing Information
Infants' Acetaminophen Dosing Change Notice

 

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Asthma Forms & Information

 

Asthma forms and information are here for your reference and use. Please contact the office if you have any questions about these forms or any concerns you may have about your child.

Asthma History Form
Asthma Action Plan

 

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Medical Records Release

As required by HIPAA privacy laws, whenever you a copy of medical records are requested for any reason we must have your written approval. Please use this form when transferring to our practice or if you need a copy of your records from other reasons.

Medical Records Release Form

 

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Miscellaneous Forms

Your physician may request that you fill out one of these forms provided here for your convenience.

 

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HIPAA Privacy Policy

 

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule

We make every effort to keep all protected health information private and secure. We have in place safeguards to protect your health information. We will reasonably limit uses and disclosures to the minimum necessary to accomplish their intended purpose. We will ensure that the use and disclose of your health information is properly safeguarded. Our procedures in place limit who can view and access health information, and we implement training programs for employees on how to protect that information. For further information concerning the privacy of your health information please see our privacy statement included in forms & policies section online. This policy is also available in our waiting rooms at each office or the front desk will be glad to give you a copy.

HIPAA Privacy Policy

 

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Employment Application

Currently we are looking for a nurse (LPN or RN). If you possess the qualifications and character to work in a busy pediatric office, then fill out our employment application. Please fax it, along with your resume, to 334-272-4876 Attn: Hiring. You may also attach your completed application and resume to an email and send to mail@mykidsdr.com.

 

Thank you for your interest in Partners in Pediatrics.

Employment Application