Clinic Forms

Clinic Forms 2018-07-02T13:16:11+00:00

Please be aware that our customer service email is not currently an encrypted email. We hope that having these forms available for you, it will save you time when you are in the office. The best route for returning forms is to bring them in when you come into the office.

Getting Started

Getting Started Guide

Information Forms for Your Visit

Patient Information
Newborn Information

If you are new to our clinic or if it has been more than a year since you completed patient information forms, please print out the Patient Information form and the HIPAA form to complete and bring with you to your child’s appointment ( please read the HIPAA Notice before completing the HIPAA form).

If you are bringing a newborn child for their first visit, you will need to also print out the Newborn Information sheet and bring a signed copy to your first appointment.

Medical Records Release Forms

Authorization Disclose
Authorization Request

If you need to have your child’s medical records copied, we have developed a process to do this. We use an outside agency called Healthport to process medical records requests and releases. Upon your request for your child’s records, Healthport will come into our office to process medical record requests. They come once per week. Their employee will scan your child’s records, sending them to their company where they are printed and mailed to the office you choose. Their charge for this is determined by the amount of papers to be scanned. They follow Arkansas law in determining what charge is made for this service.

If you are moving your child to All For Kids Pediatric Clinic, it will be helpful to have their previous medical records. Please print off and complete the Authorization to Request, send to the clinic you need to provide the records or send to us and we will get it to the other office to get the process started. If you need your medical records transferred from All For Kids Pediatric Clinic, you may print off the Authorization to Disclose and send it to us to start the process.

Forms for Patient Management

Asthma Action Plan
Athletic Physical

Clinic Handbook & Notice of Nondiscrimination

Clinic Handbook
Notice of Nondiscrimination