Four Seasons Pediatrics

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Forms

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

You can also email the form to our staff or to “bkoehler(at)fourseasonspediatrics.com”  You will need to replace (at) with @ when emailing.

You can also fax the forms to us at 518-383-3255 if that works best as well.

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

 

Complete Registration Packet (New Patient Paperwork)2018 Complete

(This includes most of the items below, so you can print the entire set of paperwork)

 

Yearly Wellness and Physical Exam Paperwork (sorted by age)

 

ADHD Forms (please note that we require return of these forms BEFORE we will schedule your appointment)

 

Release for records going to our office (transferring in)2018 records incoming

Release for records leaving our office (transferring out)2018 records outgoing

Release for medical information to be emailed or faxed (to send individual items to other locations)2018 PHI disclosure form

18 year old patient consent to speak to others (so we can talk to parents about the patient)2018 18yr old patient consent

Address change or update (please review closely)2018 address change

Insurance change or update (please review closely)2018 insurance change

HIXNY (Health Information Exchange of New York) consent (to exchange records with Urgentcare or ER)2018 HIXNY

Pediatric History Questionnaire (required for each patient individually)2018 PHQ

Healthcare Parental Proxy form (for another adult to bring your child into the office for a visit, please read closely)2018 proxy

Race and Ethnicity form (Federally required to be asked to all patients)2018 r and e form

Office Policies and Consent for treatment (just for review, please ask if you want your signed copy on file)2018 policies and consent