Office Forms – Deceriana Uy: Periatrican Rocky Point New York

office forms

IMPORTANT

Please scroll BELOW the “FORMS” section to FIND YOUR CHILD’s AGE CATEGORY to print off the required select forms in advance of your appointment to save time. Along with your completed forms, please bring your insurance card with you.

First, please make sure that our practice accepts your Insurance Plan.
If you need to select a primary care physician, as with most HMO plans, please contact your insurance company prior to your visit. Make certain that Dr. Decerina Uy is listed as your child’s primary care physician.

Adolescent Confidentiality Statement Authorization to Accompany Child Cancellation/No Show Policy Change of Address Change of Insurance Family Medical History Guarantor Agreement Initial History Non-Covered Services Agreement Nondiscrimination Notice Notice of Privacy Practices NYSIIS Patient Information Patient Information Form Patient Registration Release of Records Form Telemedicine Consent Form

Autorización para Acompañar al Niño Aviso de prácticas de privacidad Acuerdo de garante Acuerdo de servicios no cubiertos Aviso de no discriminación Cambio de dirección Cambio de seguro Declaración de confidencialidad del adolescente HISTORIAL MÉDICO FAMILIAR Información del paciente de NYSIIS Información del paciente Liberación de registros Política de cancelación / no presentación Registro de pacientes

New & Transferring Patients

Records Release / New Patient Forms

Newborns

Newborn 1st Visit Forms

Babies 1 Month to 2 Years

2 Week — 1 Month Well

Developmental Screening Neonatal History Copay, Coins, Ded, Non-covered Services Consent Form

2 Month Well

Developmental Screening Personal Social 2 Months Copay, Coins, Ded, Non-covered Services Consent Form

4 Month Well

Developmental Screening Personal Social 4 Months Copay, Coins, Ded, Non-covered Services Consent Form

6 Month Well

Developmental Screening Personal Social 6 Months Copay, Coins, Ded, Non-covered Services Consent Form

9 Month Well

Developmental Screening Personal Social 9 Months Copay, Coins, Ded, Non-covered Services Consent Form

12 Month Well

Developmental Screening Personal Social 12 Months M-CHAT Copay, Coins, Ded, Non-covered Services Consent Form

15 Month Well

Developmental Screening Personal Social History M-CHAT Copay, Coins, Ded, Non-covered Services Consent Form

18 Month Well

Developmental Screening Personal Social M-CHAT Copay, Coins, Ded, Non-covered Services Consent Form

2 Year Well

Developmental Screening Personal Social Lead Screening Copay, Coins, Ded, Non-covered Services Consent Form

Young Children ages 3-9

3 Year Well

Developmental Screening Personal Social Copay, Coins, Ded, Non-covered Services Consent Form

4-5 Year Well

Developmental Screening Personal Social Updated Family Medical History Copay, Coins, Ded, Non-covered Services Consent Form

6 Year Well

Developmental Screening Personal Social Updated Family Medical History Copay, Coins, Ded, Non-covered Services Consent Form

7 Year Well

Visit Questionnaire Personal Social Updated Family Medical History Copay, Coins, Ded, Non-covered Services Consent Form

8 Year Well

Visit Questionnaire Personal Social Updated Family Medical History Copay, Coins, Ded, Non-covered Services Consent Form

9 Year Well

Visit Questionnaire Personal Social Updated Family Medical History Copay, Coins, Ded, Non-covered Services Consent Form

Early Adolescent

10 Year Well - Male

Visit Questionnaire Personal Social Updated Family Medical History Copay, Coins, Ded, Non-covered Services Consent Form

10 Year Well - Female

Visit Questionnaire Personal Social Updated Family Medical History Copay, Coins, Ded, Non-covered Services Consent Form

11 Year Well - Male

Personal Social Teen Screen Updated Family Medical History Copay, Coins, Ded, Non-covered Services Consent Form

11 Year Well - Female

Personal Social Teen Screen Updated Family Medical History Copay, Coins, Ded, Non-covered Services Consent Form

12 Year Well - Male

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

12 Year Well - Female

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

Middle Adolescent

13 Year Well - Male

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

13 Year Well - Female

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

14 Year Well - Male

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

14 Year Well - Female

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

15 Year Well - Male

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

15 Year Well - Female

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

Late Adolescent

16 Year Well - Male

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

16 Year Well - Female

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

17 Year Well - Male

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

17 Year Well - Female

Personal Social Teen Screen Updated Family Medical History Adolescent Confidentiality Agreement Copay, Coins, Ded, Non-covered Services Consent Form

18 Year Well - Male

Personal Social PHQ Updated Family Medical History Adolescent Confidentiality Agreement HIPPA Release Copay, Coins, Ded, Non-covered Services Consent Form

18 Year Well - Female

Personal Social PHQ Updated Family Medical History Adolescent Confidentiality Agreement HIPPA Release Copay, Coins, Ded, Non-covered Services Consent Form

19 Year Well - Male

Personal Social PHQ Updated Family Medical History Adolescent Confidentiality Agreement HIPPA Release NYSIIS Consent Copay, Coins, Ded, Non-covered Services Consent Form

19 Year Well - Female

Personal Social PHQ Updated Family Medical History Adolescent Confidentiality Agreement HIPPA Release NYSIIS Consent Copay, Coins, Ded, Non-covered Services Consent Form

20 Year Well - Male

PHQ Updated Family Medical History Adolescent Confidentiality Agreement HIPPA Release NYSIIS Consent Copay, Coins, Ded, Non-covered Services Consent Form

20 Year Well - Female

PHQ Updated Family Medical History Adolescent Confidentiality Agreement HIPPA Release NYSIIS Consent Copay, Coins, Ded, Non-covered Services Consent Form

21 Year Well - Male

PHQ Updated Family Medical History Adolescent Confidentiality Agreement HIPPA Release NYSIIS Consent Copay, Coins, Ded, Non-covered Services Consent Form

21 Year Well - Female

PHQ Updated Family Medical History Adolescent Confidentiality Agreement HIPPA Release NYSIIS Consent Copay, Coins, Ded, Non-covered Services Consent Form

For more Information regarding Vaccine Information, please visit the following website at:

AAP Immunizations Page CDC Vaccine Information Sheets

As we follow the guidelines established by the American Academy of Pediatrics , please visit the following links for more information:

AAP Pediatric Patient Education AAP Bright Futures Resources for Families Healthy Children.org

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