|
FORMS
FOR NEW PATIENTS: |
|
FORMS
FOR AD/HD PATIENTS |
|
MISC FORMS |
 |
|
 |
|
 |
|
[For initial visit, periodic updates to our files.] |
|
[Long Form to be completed by parent after first AD/HD
evaluation visit] |
|
[To be completed when making an expectant parent visit
to our office] |
  |
|
 |
|
 |
|
Must be filled out for initial visit and updated
whenever there is a change in insurance status.] |
|
[Age Specific Short Form to be completed by parents and
teachers to monitor progress and make medication changes for
patients diagnosed with ADHD] |
|
To use when a caregiver other than a parent may need to
seek medical attention for the minor child at our office] |
 |
|
 |
|
 |
|
[Copy of the HIPPA Privacy Policy. Please read & then
complete the RECEIPT of HIPPA POLICY form] |
|
Age specific Short Form to be completed by parents and
teachers to monitor progress and make medication changes for
patients diagnosed with ADHD] |
|
[To request your child's records to transfer from LAP or
to request specific parts of the record to be sent to a
specialist or other entity for treatment purposes, but with the
intent to stay at LAP] |
 |
|
|
|
|
|
[Acknowledgment that you have received our HIPPA Privacy
Policy, and the form on which to indicate who is allowed to have
access to your child's medical records, and who may bring them
in for medical care.] |
|
|
|
|
 |
|
|
|
|
| [To
request your child's records from another office when
transferring your child's care to our office.] |
|
|
|
|