Practice Forms

HIPAA

New Federal laws require us to provide assurance of privacy and to attest that we will keep your personal and medical information confidential.

Download our HIPAA Forms here:

• Notice of Privacy Practices
• Notice of Privacy Practices - Spanish

New Patients

These forms can either be printed out and then filled in by hand or filled in using your computer. Should you chose to fill them out using your computer, you will not be able to save your alterations, but you will be able to print them out and bring them to your appointment.

New Patient Packet: English

1. Vaccine Compliance Signature Form
2. New Patient Welcome Letter
3. New Patient Registration Form
4. Medical History
5. Authorization to Treat
6. Release of Information
7. WPC Financial Policy
8. Acknowledgment and Consent
9. Patient Rights and Responsibilities
10. Westside Pediatrics Portal Access
11. Credit Card Authorization

New Patient Packet: Spanish

1. Vaccine Complaince Signature Form
2. New Patient Welcome Letter
3. New Patient Registration Form
4. Medical History
5. Authorization to Treat
6. Release of Information
7. WPC Financial Policy
8. Acknowledgment and Consent
9. Patient Rights and Responsibilities
10. Westside Pediatrics Portal Access
11. Credit Card Authorization

Newborn New Patient Packet: English

1. Vaccine Compliance Signature Form
2. New Patient Welcome Letter
3. New Patient Registration Form
4. Newborn Medical History
5. Authorization to Treat
6. WPC Financial Policy
7. Acknowledgment and Consent
8. Patient Rights and Responsibilities
9. Westside Pediatrics Portal Access
10. Peds One Newborn Billing Request
11. Credit Card Authorization

Newborn New Patient Packet: Spanish

1. Vaccine Complaince Signature Form
2. Vaccine Complaince Signature Form
3. New Patient Welcome Letter
4. New Patient Registration Form
5. Newborn Medical History
6. Authorization to Treat
7. WPC Financial Policy
8. Ackowledgement and Consent
9. Patient Rights and Responsibilities
10. Westside Pediatrics Portal Access
11. Peds One Newborn Billing Request
12. Credit Card Authorization

 

Other Forms

These forms can either be printed out and then filled in by hand or filled in using your computer. Should you chose to fill them out using your computer, you will not be able to save your alterations, but you will be able to print them out and bring them to your appointment.

• Authorization to Use/Disclose Health Information
• Authorization to Use/Disclose Health Information - Spanish
• Authorization to Treat
• Authorization to Treat - Spanish
• Financial Policy
• Financial Policy - Spanish
• Credit Card Authorization
• Credit Card Authorization - Spanish

ASQ and MCHAT Forms

• ASQ 10 Month Questionnaire, Completed for 9 Month Visit
• MCHAT Questionnaire, Completed for 18 Month Visit
• ASQ 24 Month Questionnaire, Completed for 2 Year Visit

Bright Futures Previsit Questionnaires

• 2-5 Day (First Week) Visit
• Newborn English
• Newborn Spanish
• 2 Month Visit English
• 2 Month Visit Spanish
• 4 Month Visit English
• 4 Month Visit Spanish
• 6 Month Visit English
• 6 Month Visit Spanish
• 9 Month Visit English
• 9 Month Visit Spanish
• 12 Month Visit English
• 12 Month Visit Spanish
• 15 Month Visit English
• 15 Month Visit Spanish
• 18 Month Visit English
• 18 Month Visit Spanish
• 2 Year Visit English
• 2 Year Visit Spanish
• 30 Month Visit English
• 30 Month Visit Spanish
• 3 Year Visit English
• 3 Year Visit Spanish
• 4 Year Visit English
• 4 Year Visit Spanish
• 5 Year Visit English
• 5 Year Visit Spanish
• 6 Year Visit English
• 6 Year Visit Spanish
• 7 Year Visit English
• 7 Year Visit Spanish
• 8 Year Visit English
• 8 Year Visit Spanish
• 9 Year Visit English
• 9 Year Visit Spanish
• 10 Year Visit English
• 10 Year Visit Spanish
• 11-14 Year Visit Parent English
• 11-14 Year Visit Patient English
• 11-14 Year Visit Parent English
• 11-14 Year Visit Patient Spanish
• Older Child/Younger Adolescent Visits
• 15-17 Year Visits Parent English
• 15-17 Year Visits Patient English
• 15-17 Year Visits Parent Spanish
• 15-17 Year Visits Patient Spanish
• 18-21 Year Visits English
• 18-21 Year Visits Spanish