Patient Forms

New Patients

Prior to your first appointment you will receive an email with a link to all the forms you’ll need to complete before your first visit.  This link will also allow you to electronically sign and return documents securely.

If you are not able to complete forms through the link sent to you, you may also access them below as a packet or individually.

New Patient Packet

This packet contains;

  • How Did You Hear About Us?
  • New Patient Registration
  • Authorization of Treatment and Assignment of Benefits
  • Receipt of Notice of Privacy Practices
  • Financial Policy
  • Patient Authorization Signatures
  • Advance Beneficiary Notice (ABN)
  • Patient Family History
  • Patient Medical History
  • Notice of Privacy Practices
  • Medical Records Release Authorization

Individual Forms

How did you Hear About us?

New Patient Registration

Authorization of Treatment and Assignment of Benefits

Notice of Privacy Practices

Financial Policy

Patient Authorization Signatures

Advance Beneficiary Notice (ABN)

Patient Family History

Patient Medical History

Medical Record Release Authorization – Authorizes us to receive records from an outside organization or other medical practice

Authorization to Release Medical Records –  Authorizes us to release records to an outside organization such as a school, daycare or other medical practice

Update Current Registration Information

 

ADHD

ADHD Information Packet – Helpful information for parents who are concerned that their child may have ADHD

General

TB and Lead Screening  – Parent Questionnaire for Tuberculosis and Lead Screening

Pre-participation Physical Evaluation – Completed by both the parent (history/demographic) and pediatrician (physical and medical clearance).  This form is utilized to show a child is medically able to participate in a specific activity.

Patient Satisfaction Survey

Electronic Request via Patient Portal

Many requests for records can be made through our patient portal. These include requests for referrals, immunization records requests and hearing and vision records requests. Simply sign into the patient portal and send us an email request for any of these items.

Referral Request – to complete this form you will need the following information about the specialist you are being referred to: specialist’s name (or if scheduled with a physician’s assistant or nurse practitioner, their supervising physician), date of the appointment, address and phone / fax number of practice

Immunization Records Request – if this will be released to an outside organization, you’ll also need to complete the Authorization to Release Medical Records

Hearing and Vision Records Request – if this will be released to an outside organization, you’ll also need to complete the Authorization to Release Medical Records

Special Note on Forms

Physical Forms – require 48-72 hours for completion. There is NO CHARGE when these forms are dropped off at the time of your well child/sports exam. Otherwise a fee of $10 will be charged.

Immunization Records (Form 3231) – requires 48-72 hours for completion. Your child MUST BE FULLY UP TO DATE on all required immunizations.

Read about the current GA STATE LAW. There is NO CHARGE when requested at the time of your child’s well visit.

Hearing and Vision Records (Form 3300) – requires 48-72 hours for completion. Your child MUST be up to date on their well-child visit AND have a valid hearing and vision exam within the last 12 months.

Katie Beckett Forms – require 7-14 business days for completion. Your child must be up to date with their well child exams and have any/all supporting documentation from specialists, labs, therapist, and counselors on file with Kennesaw Pediatrics. These comprehensive forms require a great deal of time and review. As a result, a fee of $25 is due when you make your request. You are responsible for ensuring all appropriate documentation is present at the time of your request. Please note, that successful filing of a Katie Becket Waiver makes the child eligible for medicaid. Since Kennesaw Pediatrics cannot accept medicaid, you may need to have a new pediatrician lined up for a smooth transition of care in order to fully utilized Katie Beckett benefits.

Family Medical Leave Act (FMLA) Form – requires 7-14 business days for completion. There is a $25 fee for completing due at the time of your request regardless of the outcome.