For your convenience, we have provided
the following forms on-line to save you time on your first appointment,
and so that the doctor can see your child more quickly. Please print,
complete and turn in these forms when you come in. Fill in all applicable
blanks even if they may seem redundant at first. If your child is
already a patient, please let us know if any of your information
Sheet On-Line Form or Face
Sheet Printable Form
This is the first form in your child’s file. It requests
non-medical information about your child and your family, as well
as your emergency and insurance information.
This form requests information that includes your child’s
medical history, family profile, feeding and nutrition, and behavioral
Any symptoms your child reports or exhibits, as well as school
history and unusual behavior, if any.
Notice 1: Privacy Practices
This describes how medical information about you or your child
may be used or disclosed, and how you can access this information.
Notice 2: Patient Questionnaire
A list of persons you authorize to receive medical condition information
and how you want confidential information conveyed to you.
Notice 3: Use or Disclosure of Protected Health Information
A list of entities, types of protected health information, and
purposes for which you authorize use and disclosure.
for Release of Medical Records
Use this form to authorize a third party, such as another doctor's
office, to release your medical records or your child's medical
records to Dr. Piga's office.
to Release Medical Information
Use this form to authorize Dr. Piga's office to disclose your
medical information or your child's medical information to a third
party, such as the office of another doctor or specialist.
Authorization for Minors
Use this form to authorize treatment for a child or minor patient
accompanied by someone other than a parent or guardian.
*HIPAA – Health Insurance Portability and Accountability
Act of 1996.
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