Office Forms

Before your appointment, please print and fill out any of the necessary forms below. 

If you have questions about how to obtain records from or send records to another provider, please call our office at 585-244-9720.

To view the forms listed below, you will need Adobe Reader.

Administrative and New Patient Forms:

• Demographic Form
• Permission Regarding Communication (HIPAA) Form
• Adult-Patient Authorization (for patients 18 years & older)
• Family Medical History Form
• Release of Records Form
• Release of Records From Former Pediatrician
• NY State COVID Vaccine Form

Well Visit Questionnaires:

• ASQ – 9 Month Questionnaire
• ASQ – 18 Month Questionnaire
• ASQ – 30 Month Questionnaire
• M-CHAT – for 18 month and 2 year visits

ADD/ADHD Forms & Questionnaires:

• ADHD Questionnaire – for Parent to Complete
• Vanderbilt Assessment – Parent Form
• Vanderbilt Assessment – Teacher Form
• Adult ADHD Self-Report Scale – Patient Form
• Vanderbilt Assessment – FOLLOW-UP – Parent Form
• Vanderbilt Assessment – FOLLOW-UP – Teacher Form

Mental Health Forms:

• Confidential Family Mental Health Survey
• Patient Health Questionnaire (PHQ.9)
• Screen for Child Anxiety Related Disorders (SCARED) – PARENT FORM
• Screen for Child Anxiety Related Disorders (SCARED) – PATIENT FORM

COVID-19 Vaccine Forms

• COVID-19 Pre-Vaccination Screening Form
  • Please print & bring completed form to your COVID vaccine appointment

Patient Portal:

• PATIENT PORTAL CONSENT

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

Under the law, health care providers need to give patients who do not have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good FaithEstimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.

For Questions or More Information
About Your Right To A
Good Faith Estimate:

visit www.cms.gov/nosurprises
or call the Elmwood Pediatric Group Billing Department at 585.244.9841.