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© 2016 by Mercer Island Pediatrics.

New Patient Privacy Practices Form

This notice describes how medical information about you may be used  and disclosed and how you can get  access to this information.  Please review it carefully.
 

Medical Records Release Form

Authorization form for MIPA to disclose records to third-parties

New Patient Packet

Registration form, financial policy and privacy practices agreements, and past patient/family medical history.

 

Please complete the family medical history with as much detail as possible -- we can use this information for reference over the course of your child's life. As with all other patient records, it will be kept confidential.

 

Change of Information Form

New address or insurance? Fill in your updated info on the registration form (you may leave other sections blank) and bring to your next appointment.

 

Authorization for Disclosure, Patients 18 or Older

This form is to be completed by patients over the age of 18 that want their parent/guardian to be able to access certain types of healthcare information on their behalf, such as requesting medication refills, picking up rx's, or scheduling appointments.

Authorization to Provide Informed Consent for a Minor

Authorization form that, in the event of need for routine or emergency medical care, allows a named individual (such as a grandparent or family friend) to provide informed consent for a minor in the absence of their legal guardian.

 

Named individuals will be required to provide self-identification.

School/Camp/Sports Forms

Sports participation, med-at-school, and other forms for local school districts.

 

Please complete the patient/history portion of forms prior to exam appointment - doctors are unable to complete and sign until you have done so.

WA State Dept. of Health Medication Exemption Form

Form stating exemption from immunizations for religious, personal, philosophical, and medical reasons.

 

 

If you wish to have any forms mailed back to you, please provide us with a self-addressed and stamped envelope.

Patient Forms