Forms
To save time at your visit, we strongly encourage all patients to print and bring their filled out forms to the appointment. You may:
- email the form to our staff or to “bkoehler(at)fourseasonspediatrics.com” You will need to replace (at) with @ when emailing.
- 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.
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: 2018 Complete
Well Visit Forms click link below:
ADHD Forms click below:
Consent and Record Release forms:
- 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
Updated information:
- Address change or update (please review closely): 2018 address change
- Insurance change or update (please review closely): 2018 insurance change
Other Forms:
- 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
4,377 total views, 22 views today