We are delighted to have your child as a patient and appreciate the opportunity to be their primary medical care provider. Please review our welcome letter attached. Below you will find the new patient forms necessary for your child’s first appointment.
New Patient Forms
Please complete the New Patient Forms in order to begin the process of joining Woodburn Pediatric Clinic.
This form authorizes someone you trust to bring in your child for same day appointments only. This allows the listed people to give consent for all medical and/or surgical treatment that may be required for your child during your absence. It also authorizes the named individuals to make, change, and/or cancel medical appointments for the patient.
HIPPA stands for Health Insurance Portability and Accountability Act, which aims at protecting the sharing and accessing of medical and personal information. This form allows Woodburn Pediatric Clinic to use and disclose health information for various reasons detailed in the document attached.
Financial Policy Form
It is our goal to make sure you receive the maximum financial benefit from your insurance provider and to make sure that your account is handled in the most efficient manner possible. In order to accomplish this goal, it is important that we have your understanding and cooperation to our financial policies attached.
Health Information Authorization
This form authorizes Woodburn Pediatric Clinic to use or disclose protected health information such as immunization record, hospital record, and more outlined in the document attached to the recipient of your choosing.
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.