Forms & Policies

Forms to print and bring to the office

Advocare Child/Dependent Patient Registration
Advocare Assignment of Benefits
Advocare HIPAA Acknowledgement of Privacy Practices
Advocare Consent Disclosure Authorization
Advocare Newborn Insurance Reminder
Patient Medical History Questionnaire
Authorization by Parent or Legal guardian for Another Person to Bring Minor to Physician's Office

Reference forms for your records

New Patient Welcome Letter
Advocare Practice Philosophy
Advocare Payment Policy
Advocare Guide to Understanding Your Statement
Advocare Notice of Privacy Practices

Additional Forms

Records Release Authorization- Joining Advocare Summit Pediatrics
Records Release Authorization- Transferring Practices
18 Year Old Letter and Authorization for Disclosure and Use of Health Information
Mental Health Release of Information

Asthma Action Plan

Asthma Treatment Plan

ADHD

Initial Teacher Vanderbilt Assessment
Initial Parent Vanderbilt Assessment
Initial Parent Vanderbilt Assessment-Spanish

Follow-Up ADHD

Follow-up Teacher Vanderbilt Assessment
Follow-up Parent Vanderbilt Assessment
Follow-Up Parent Vanderbilt Assessment-Spanish

Concussions

Concussion Fact Sheet-English
Concussion Fact Sheet-Spanish
Preventing Concussions-English
Preventing Concussions-Spanish

Developmental Forms

M-CHAT English
Modified Checklist for Autism in Toddlers (M-CHAT)
M-CHAT Spanish
M-CHAT-Portuguese
M-CHAT Italian
M-CHAT French
M-CHAT Chinese
M-CHAT Korean

Food Allergies

Food Allergy Emergency Care Plan

Health Forms

Preparticipation Physical Evaluation
Universal Child Health Record
NYC Child Adolescent Health Examination Form