Our Staff at Healthy Kids Pediatric Group would like to welcome you and thank you for selecting us to provide your child’s medical care. As a new patient, you will naturally have many questions regarding the policies and practices of our pediatric office. Hopefully the information which follows will be helpful to you as we get to know each other.
How To Transfer Into Our Practice
- Please use the forms below to begin the process of transferring into our practice.
- Please fill in the appropriate sections and send to your previous doctor.
- You may also print these forms and bring them with you to your first appointment at our office.
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Annual Patient Packet Forms
- Adult Patient Registration (PDF)
- Annual Consent and Acknowledgement (PDF)
- Aviso de Prácticas de Privacidad (PDF)
- Child Registration (PDF)
- Consentimiento y Reconocimiento Anual (PDF)
- Notice of Privacy Practices (PDF)
- Pediatric Family Registration (PDF)
- Registro de Niños (PDF)
- Registro de Pacientes Adultos (PDF)
- Registro Familiar Pediátrico (PDF)
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Patient Facing Forms
- Authorization for Use & Disclosure of Protected Health Information (PHI) (PDF)
(Medical Records Release) - Authorization to Bring a Minor (PDF)
- Case Registration (PDF)
- Healow Trifold (PDF)
- Health Information Exchange (HIE): FAQs (PDF)
- Health Information Exchange (HIE): Opt-Out (PDF)
- Informed Consent: In-Office Procedures (PDF)
- New Jersey Immunization Information System (NJIIS): Consent (PDF)
- Newborn Insurance Reminder (PDF)
- Patient Consent to Draw/Test Blood (PDF)
- Patient Financial Responsibility (PDF)
- Patient Portal Proxy Authorization (PDF)
(18 years or older) - Patient Portal: FAQs (PDF)
- Patient Portal: Flyer (PDF)
- Practice & Payment Philosophy (PDF)
- Recordatorio de Seguro Para Recién Nacidos (PDF)
- Restriction of Disclosure to Health Plan (PDF)
- SureScripts: Opt-Out (PDF)
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Additional Forms
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Assessment Forms
- Edinburgh Postnatal Depression Scale (PDF)
(Complete prior to the 1 month checkup) - MCHAT, Revised Follow-Up: Checklist Only (PDF)
(Modified Checklist for Autism in Toddlers - Complete for 18 and 24 month well child checks) - MCHAT, Revised Follow-Up: Packet with Checklist (PDF)
(Modified Checklist for Autism in Toddlers - Complete for 18 and 24 month well child checks) - NICHQ Vanderbilt Assessment: Follow-Up (Parent) (PDF)
- NICHQ Vanderbilt Assessment: Follow-Up (Teacher) (PDF)
- NICHQ Vanderbilt Initial Assessment (Parent) (PDF)
- NICHQ Vanderbilt Initial Assessment (Teacher) (PDF)
- PSC-Y Report (PDF)
(Pediatric Symptom Checklist - Youth Report)
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Well Child Developmental Screens
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