For your convenience, we have provided the following forms on-line to save you time on your first appointment, and so that the doctor can see your child more quickly. Please print, complete and turn in these forms when you come in. Fill in all applicable blanks even if they may seem redundant at first. If your child is already a patient, please let us know if any of your information has changed.

  1. Patient Demographics On-Line Form  or  Patient Demographics Printable Form
    This is the first form in your file. It requests non-medical information about the patient, as well as emergency and insurance information.
  2. Pediatric Health History
    For pediatric patients, this form requests information that includes your child’s medical history, family profile, feeding and nutrition, and behavioral development.
  3. Notice of Privacy Practices (HIPAA)
    A list of persons you authorize to receive medical condition information and how you want confidential information conveyed to you.
  4. Request for Release of Medical Records
    Use this form to authorize the release of your medical records or your child's medical records to or from Piga Primary Care Associates and a third party, such as another doctor's office.
  5. Medical Authorization for Minors
    Use this form to authorize treatment for a child or minor patient accompanied by someone other than a parent or guardian.
  6. Billing Waiver
    Information and waiver for services that may not be covered or may only be partially covered by insurance.
  7. Office Billing Policies
    Information on appointments, after-hours telephone calls, medical records, prescriptions, physical exam forms and account statements.

  1. Patient Demographics On-Line Form  or  Patient Demographics Printable Form
    This is the first form in your file. It requests non-medical information about the patient, as well as emergency and insurance information.
  2. Adult Medical History
    For adult patients, this form requests information that includes your medical history, family profile, immunizations and behavioral history.
  3. Notice of Privacy Practices (HIPAA)
    A list of persons you authorize to receive medical condition information and how you want confidential information conveyed to you.
  4. Request for Release of Medical Records
    Use this form to authorize the release of your medical records or your child's medical records to or from Piga Primary Care Associates and a third party, such as another doctor's office.
  5. Billing Waiver
    Information and waiver for services that may not be covered or may only be partially covered by insurance.
  6. Office Billing Policies
    Information on appointments, after-hours telephone calls, medical records, prescriptions, physical exam forms and account statements.

 

Get Adobe Reader You must have Adobe Reader© installed on your computer to view the PDF documents.