{"id":1108,"date":"2016-10-28T11:15:07","date_gmt":"2016-10-28T15:15:07","guid":{"rendered":"http:\/\/007.488.myftpupload.com\/?page_id=1108"},"modified":"2021-01-23T01:10:02","modified_gmt":"2021-01-23T01:10:02","slug":"forms","status":"publish","type":"page","link":"https:\/\/peopleil.wwwls25.a2hosted.com\/CHAPIN\/office-information\/forms\/","title":{"rendered":"Forms"},"content":{"rendered":"[vc_row][vc_column width=”1\/5″][\/vc_column][vc_column width=”1\/5″][vc_raw_html]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[\/vc_raw_html][\/vc_column][vc_column width=”1\/5″][vc_raw_html]JTNDZm9ybSUyMG5hbWUlM0QlMjJQb3J0YWwlMjIlMjBtZXRob2QlMjAlM0QlMjAlMjJwb3N0JTIyJTIwYWN0aW9uJTIwJTNEJTIwJTIyaHR0cHMlM0ElMkYlMkZjaGFwaW5wZWRpYXRyaWNzLmZvbGxvd215aGVhbHRoLmNvbSUyRiUyMiUzRSUzQ2lucHV0JTIwY2xhc3MlM0QlMjJwYXlfaW52b2ljZSUyMiUyMHR5cGUlMjAlM0QlMjAlMjJzdWJtaXQlMjIlMjB2YWx1ZSUyMCUzRCUyMCUyMkFjY291bnQlMjBMb2clMjBJbiUyMiUyMCUyRiUzRSUyMCUzQyUyRmZvcm0lM0U=[\/vc_raw_html][\/vc_column][vc_column width=”1\/5″][vc_raw_html]JTNDZm9ybSUyMG5hbWUlM0QlMjJDb250YWN0LVVzJTIyJTIwbWV0aG9kJTIwJTNEJTIwJTIycG9zdCUyMiUyMGFjdGlvbiUyMCUzRCUyMCUyMmh0dHBzJTNBJTJGJTJGY2hhcGlucGVkaWF0cmljcy5jb20lMkZjb250YWN0LXVzJTJGJTIyJTNFJTIwJTNDaW5wdXQlMjBjbGFzcyUzRCUyMnBheV9pbnZvaWNlJTIyJTIwdHlwZSUyMCUzRCUyMCUyMnN1Ym1pdCUyMiUyMHZhbHVlJTIwJTNEJTIwJTIyQ29udGFjdCUyMFVzJTIyJTIwJTJGJTNFJTIwJTNDJTJGZm9ybSUzRQ==[\/vc_raw_html][\/vc_column][vc_column width=”1\/5″][\/vc_column][\/vc_row][vc_row el_class=”Primary2″][vc_column width=”1\/4″][\/vc_column][vc_column width=”1\/2″][vc_column_text]\n

Patient Forms<\/h1>\n

General Forms<\/h2>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
\n

Patient Demographic Form<\/p>\n<\/td>\n

PDF<\/a>\u00a0(updated:\u00a02018\u00a0September)<\/span><\/td>\n<\/tr>\n
\n

Notice of Privacy Practices – HIPAA<\/p>\n<\/td>\n

PDF<\/a>\u00a0(updated:\u00a02018\u00a0September)<\/span><\/td>\n<\/tr>\n
\n

Receipt of Privacy Practice Notice – HIPAA<\/p>\n<\/td>\n

PDF<\/a>\u00a0(updated:\u00a02018\u00a0September)<\/span><\/td>\n<\/tr>\n
\n

Authorization Form – HIPAA<\/p>\n<\/td>\n

PDF<\/a>\u00a0(updated:\u00a02018\u00a0September)<\/span><\/td>\n<\/tr>\n
\n

Financial Policy<\/p>\n<\/td>\n

PDF<\/a>\u00a0(updated:\u00a02018\u00a0September)<\/span><\/td>\n<\/tr>\n
\n

Release of Medical Information<\/p>\n<\/td>\n

PDF<\/a>\u00a0(updated:\u00a02018\u00a0September)<\/span><\/td>\n<\/tr>\n
\n

Authorization to Treat a Minor Patient in Absence of Parent or Guardian<\/p>\n<\/td>\n

PDF<\/a>\u00a0(updated:\u00a02018\u00a0September)<\/span><\/td>\n<\/tr>\n
\n

NICHQ Vanderbilt Assessment Scale – Parent Form<\/p>\n<\/td>\n

PDF<\/a><\/td>\n<\/tr>\n
\n

NICHQ Vanderbilt Assessment Scale – Teacher Form<\/p>\n<\/td>\n

PDF<\/a><\/td>\n<\/tr>\n
\n

Records Request-Release<\/p>\n<\/td>\n

PDF<\/a>\u00a0(updated:\u00a02018\u00a0September)<\/span><\/td>\n<\/tr>\n
\n

Edinburgh Postnatal Depression Scale<\/p>\n<\/td>\n

PDF<\/a><\/td>\n<\/tr>\n
\n

M-CHAT<\/p>\n<\/td>\n

PDF<\/a><\/td>\n<\/tr>\n
\n

Patient Health Questionnaire (PHQ-9)<\/p>\n<\/td>\n

PDF<\/a><\/td>\n<\/tr>\n
\n

Prenatal Questionnaire<\/p>\n<\/td>\n

PDF<\/a><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n[\/vc_column_text][\/vc_column][vc_column width=”1\/4″][\/vc_column][\/vc_row][vc_row el_class=”Primary1″][vc_column width=”1\/4″][\/vc_column][vc_column width=”1\/2″][vc_column_text]\n

Flu Season Forms<\/h2>\n\n\n\n
Flu Injection<\/td>\nClick here to download<\/a> (updated: 2020 September)<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n[\/vc_column_text][\/vc_column][vc_column width=”1\/4″][\/vc_column][\/vc_row][vc_row el_class=”Secondary2″][vc_column width=”1\/4″][\/vc_column][vc_column width=”1\/2″][vc_column_text]The above forms are in a PDF format.\u00a0 If you are not able to open it, you will need to download the Adobe PDF reader to do so.\u00a0 This reader can be downloaded for free by clicking here: ADOBE PDF READER<\/a>[\/vc_column_text][\/vc_column][vc_column width=”1\/4″][\/vc_column][\/vc_row][vc_row][vc_column][vc_single_image source=”featured_image” img_size=”large” alignment=”center”][\/vc_column][\/vc_row]\n","protected":false},"excerpt":{"rendered":"

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General Forms Patient Demographic Form PDF\u00a0(updated:\u00a02018\u00a0September) Notice of Privacy Practices – HIPAA PDF\u00a0(updated:\u00a02018\u00a0September) Receipt of Privacy Practice Notice –<\/p>\n","protected":false},"author":1,"featured_media":1837,"parent":42,"menu_order":5,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"yoast_head":"\nForms -<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/chapinpediatrics.com\/office-information\/forms\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Forms -\" \/>\n<meta property=\"og:description\" content=\"[vc_row][vc_column width=”1\/5″][\/vc_column][vc_column 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General Forms Patient Demographic Form PDF\u00a0(updated:\u00a02018\u00a0September) Notice of Privacy Practices – HIPAA PDF\u00a0(updated:\u00a02018\u00a0September) Receipt of Privacy Practice Notice –\" \/>\n<meta property=\"og:url\" content=\"https:\/\/chapinpediatrics.com\/office-information\/forms\/\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/chapinpediatrics\" \/>\n<meta property=\"article:modified_time\" content=\"2021-01-23T01:10:02+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/peopleil.wwwls25.a2hosted.com\/CHAPIN\/wp-content\/uploads\/2010\/05\/forms-opt-2.jpg\" \/>\n\t<meta property=\"og:image:width\" content=\"1396\" \/>\n\t<meta property=\"og:image:height\" content=\"1047\" \/>\n<meta name=\"twitter:card\" content=\"summary\" \/>\n<meta name=\"twitter:creator\" content=\"@ChapinPediatric\" \/>\n<meta name=\"twitter:site\" content=\"@ChapinPediatric\" \/>\n<script type=\"application\/ld+json\" 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