Patient Forms


 

For your convenience, we have made several patient forms available to be downloaded and printed prior to your visit. By completing these forms in advance, you will help us to serve you in a more efficient manner.


New Patient Forms:

Office Policies and Consent Forms

History Questionnaire

 

Demographic FORM

 

Patient Portal Registration

 

CONSENT TO TREAT MINOR CHILD

 

Notice of Privacy Practices

  


School Forms:

Policy for Completion of School Forms

Forms Request

(use this to request the completion of any form)
 

Sports Physical Form

(Physical Forms will not be completed during an office visit.)  


ADHD Treatment Forms: 

ADHD Parent Follow Up

ADHD Parent Initial

 

ADHD Teacher Follow Up

 

ADHD Teacher Initial

  


Medical Release Forms:

Medical Records Release – INCOMING

(to request a copy of your child's records to be sent to another practice)
 

Medical Records Release – OUTGOING

(to request a copy of your child's records to be sent to another practice)
 

Medical Records Release – MENTAL HEALTH

(to request your child's mental or behavioral health records be sent to another office)  


What to Expect

Upon arrival, you will be asked for the completed forms (unless you faxed the forms in advance) AND the following items:

•If your Health Plan requires a Co-payment, it will be collected when you check in.

•Photo ID of Parent or Guardian

•Health Plan Insurance ID Card (MUST BE CURRENT) for each active policy for the patient

•Previous medical records if applicable

 

Insurances Accepted

We accept most commercial insurances. For any coverage-related questions, please contact our office.

Aetna
Amerigroup
Anthem Blue Cross Blue Shield
CareSource
Cigna
Humana
Multiplan
Peach State Health Plan
PHCS
United Health Care
WellCare
Location
The Pediatric Center of Stone Mountain
5405 Memorial Drive, Building D
Stone Mountain, GA 30083
Phone: 404-296-3800
Fax: (404) 297-8753
Office Hours

Get in touch

404-296-3800