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KID FORMS

online forms

Madison Pediatrics



Protected Health Information Form

(Fill. Submit. Done.)



Date: *
CalendarNow(GMT - 05.00)

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Please list the people, if any, to whom we may release information about your child's general medical condition and/or diagnoses (including treatment, operations, and payment information.)


(Type your first and last name.)






(Type your first and last name.)






(Type your first and last name.)






(Type your first and last name.)




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Please list the mailing address where you would like billing statements and/or correspondence from our office sent, if other than your home.
Use Address:












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Please list the preferred phone number for receiving calls about appointments, lab & x-ray results, and other patient information.
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This is a: *


(You acknowledge that mobile phones are not secure and private lines.)
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Confidential messages or appointment reminders may / may not be left on your answering machine or voicemail.
Confidential info may be left on answering machine and/or voicemail: *


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Would you prefer no phone calls or contact via our Online Care Center, having ALL correspondence via standard mail? (This includes appointment reminders and other routine communications.)
DO NOT CALL. I prefer all correspondence to be sent in a sealed envelope marked "CONFIDENTIAL.":

(Leave unchecked if you prefer normal communications.)
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By signing this form (typed signature), you are certifying the accuracy of this information and agreeing to send the information to Madison Pediatrics, Inc., for inclusion into your child's records.