Patient Forms
Ages & Stages Questionnaires® - 9 months
Ages & Stages Questionnaires® - 18 months
Authorization for assignment of benefits
Interpreter Services Form
Medical Record Release from ICC
Authorization for ICC to release medical records
Authorization to disclose information to ICC
First time patient information form
Notice of Nondiscrimination Form
Permission for children to be seen with non-parent/guardian
Notice of Privacy Practices
Alabama High School Athletic Association Physical Form
Please complete page 1 prior to submitting physical form to our office
Standard Office Forms
Translated Into Spanish
Ages & Stages Questionnaires® - 9 months
Ages & Stages Questionnaires® - Cuestionario de 9 meses
Ages & Stages Questionnaires® - 18 months
Ages & Stages Questionnaires® - Cuestionario de 18 meses
Authorization for assignment of benefits
AUTORIZACIÓN PARA ASIGNACIÓN DE BENEFICIOS
Y
AUTORIZACIÓN PARA DIVULGAR O RECIBIR INFORMACIÓN MÉDICA
Medical Record Release from ICC - Spanish
Authorization for ICC to release medical records
Autorización para divulgar información médica protegida
Medical Record Release to ICC - Spanish
Authorization to disclose information to ICC
Autorización para divulgar información médica protegida
First time patient information form
Por favor escriba todos los pacientes que se encuentran actualmente en nuestra práctica.
Notice of Nondiscrimination Form
La discriminación es ilegal
Permission to be Seen - Spanish
Permission for children to be seen with non-parent/guardian
PERMISO PARA QUE NIÑOS SEAN VISTOS POR MEDICO CON OTRA PERSONA A PARTE DE PADRES/GUARDIAN
Notice of Privacy Practices
AVISO DE PRÁCTICAS DE PRIVACIDAD