Patient Forms
• Authorization for Release of Medical Information (PDF) – Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.
Autorización De HIPAA Para Divulgar Información Del Paciente
• Authorization and Consent for Treatment (PDF). – All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.
Autorización y Consentimiento Para el Tratamiento
• Patient Designated Contacts (PDF) – Patients are encouraged to complete and return the Patient Designated Contacts Form but it is not required. Contactos designados del paciente
• Informed Consent for Telehealth Services (PDF)– This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology. Consentimiento informado para servicios de telesalud
• Health Information Exchange Opt-Out This form allows patients to opt out of sharing their PHI via the Health Information Exchange (HIE). The HIE securely shares patient information electronically among a network of healthcare providers, such as physicians, hospitals, labs, and pharmacies. Formulario de solicitud de exclusión voluntaria de Privia HIE
• Florida High School Athletic Association Sports Participation Physical Form
Vaccine Information
• Recommended vaccine schedule
• pediatric vaccine education resources
Common Illness Guides
• Fever guidance
• flu / RSV / strep information
• Tylenol / Motrin dosage guidance
• non-urgent parent education resources
Office Policies
• Financial policy– This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations. Política Financiera (PDF)
• Notice of Privacy Practices– Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully. Aviso de prácticas de privacidad
• Late arrival / scheduling guidance
Insurance & Fees
Use a clean summary page with most major plans accepted, no Medicaid participation, verify current coverage before appointment, self-pay / out-of-network information, and no-show / missed appointment fees.
Patient Portal
Forms can be completed online through the Patient portal or you can print them from our website and bring them with you to your appointment.
Include clear access for forms, appointment messages, medication requests, and non-urgent messages.
Language services Notice of Nondiscrimination
JAX PEDS
PS DESIGN