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