For New Patients

Welcome to Pediatric Associates California. In this section you will find the forms that you need (in PDF format) to complete before your first visit. By doing this at home you will save some time on your first visit.

1. Patient Information (demographic information). Print this form and complete: Patient Information-E

2. Initial History Questionnaire (medical history). Print this forms and complete: Initial Questionnaire-E-1 (page 1) and Initial Questionnaire-E-2 (page 2).

3. HIPAA Notice of Private Practices. This is a description of the privacy requirements that we follow. You can print it for your records or read it in our website. You do not have to bring it to your first visit. HIPAA Notice of Privacy Practices in PDF

4. Acknowledgemet of Receipt of Notice of Private Practices. Print this form and complete. Acknowledgement of Receipt of Notice of Private Practices in PDF

5. HIPAA Compliant Release of Records FormWe only need this form if you are transferring care from another physician. You can print this form, complete it and take it to your prior health care provider, so he/she can send us your child’s records. If your child has no major medical problems, we will need a copy of the last physical exam, immunization records and growth chart. HIPAA Compliant Release of Records Form in PDF

Also, don’t forget to bring your insurance card. If you need to select a provider (specially patients with HMO) make sure you select us as your primary care provider before your appointment.