To save time at your visit, we strongly encourage all patients to print and bring their filled out forms to the appointment.

You mail email (by scanning or taking a photo with your phone) any forms to: Exchange@fourseasonspediatrics.com. You may fax the form to us at 518-383-3255 if that works best.

Please note that all forms that require a signature must be hand signed, we will not accept a typed or digital signature.

Flu Vaccine Screening Form Link-Please complete prior to arrival

Registration Forms (this includes most of the items below, so you can print the entire set at one time)

• Complete Registration Packet (New Patient Paperwork) – click this link: Registration Packet v2019

Well Visit Forms click link below:

• Please note that we are transitioning to the use of forms through CHADIS. Click here to We prefer you use these forms as they are very complete and improve care. Log into your web portal through a browser (not the Healow App). On the homepage, look for the Milestones Tile. If you are within 2 weeks of your well visit, you will see a button under Milestones called CHADIS. Click this button and it will show all questionnaires we want you to fill out. Please try to do at least one day before your appointment. Thank you.
• Well Physical Exam Forms – Only use these now if you do not have a web portal account

ADHD Forms click below:

• Please note that we are transitioning to the use of forms through CHADIS. We prefer you use these forms as they are very complete and improve care. If you have not used it yet, please call our office. Ask our staff to create an account with an invitation code. Once your account is set up, staff will assign questionnaires for you to fill out. These are forms that use the newer DSM 5 criteria. Once set up, you can log in directly or log into your web portal account. Open a browser (not the Healow App). On the homepage, look for the Milestones Tile. If you are within 2 weeks of your ADHD visit OR you can request staff to assign ADHD questionnaires to schedule an appointment. When you login to your portal account, you will see a button under Milestones called CHADIS. Click this button and it will show all questionnaires we want you to fill out. Please try to do at least one day before your appointment. Thank you.
• Once you have logged into CHADIS, click here to learn how to INVITE A TEACHER. It only has to be done once.
• Once you have logged into CHADIS, click here to learn how to INVITE YOUR TEEN to answer questionnaires. It only has to be done once
• ADHD Forms (Initial evaluation click here. For follow up visits, we now prefer CHADIS rather then the forms above – in either case, please note that we require return of these forms BEFORE we will schedule your appointment)

Consent and Record Release forms: You mail email (by scanning or taking a photo with your phone) any forms to: Exchange@fourseasonspediatrics.com or fax to the number listed above.

• Release for records going to our office (transferring in): Records release incoming v2018
• Release for records leaving our office (transferring out): Records release outgoing v2019
• Release for medical information to be emailed or faxed (to send individual items to other locations such as your school): PHI disclosure form
• 18 year old patient consent to speak to others (so we can talk to parents about the patient): 18 year old patient consent v2018

Updated information:

• Address change or update (please review closely): Address change v2018
• Insurance change or update (please review closely): Insurance change v2018

Other Forms:

• Pediatric History Questionnaire (required for each patient individually) History Questionnaire v2018
• Healthcare Parental Proxy form (for another adult to bring your child into the office for a visit, please read closely) Proxy Form v2018
• Race and Ethnicity form (Federally required to be asked to all patients) Race and Ethnicity Form v2018
• Office Policies and Consent for treatment (for review, please ask if you want your signed copy on file) Policies and consent form v2018

 20,366 total views,  1 views today