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Fairmount Pediatrics

Forms

Vaccine Consent - Turkish
18-year old: ADULTHOOD Letter (PDF)
ABN – Advanced Beneficiary Notice of Noncoverage (Medicare only) (PDF)
ABN – Aviso Anticipado de No Cobertura Para el Beneficiario (Medicare Solamente) (PDF)
ABN - Form Instructions
Advocare Beyfortus Patient Liability Form
Advocare Newborn Insurance Reminder - SPANISH
Authorization for Use & Disclosure of Protected Health Information (PHI) (PDF)
(Medical Records Release)
Authorization to Bring a Minor (PDF)
Autorización para el uso y divulgación de información médica protegida (PHI) (PDF)
Cancellation of Prior Health Information Exchange (HIE): Opt-Out (PDF)
Cancellation of Prior SureScripts: Opt-Out (PDF)
Case Registration (PDF)
Estimated Cost: Out-of-Network Services (PDF)
Formulario de responsabilidad financiera del paciente de Advocare
Healow Trifold (PDF)
Health Information Exchange (HIE): FAQs (PDF)
Health Information Exchange (HIE): Opt-Out (PDF)
IMM Withdrawal from NJIIS
Informed Consent: In-Office Procedures (PDF)
Informed Consent: Surgical Procedure or Invasive Treatment Procedure (PDF)
New Jersey Immunization Information System (NJIIS): Consent (PDF)
Newborn Insurance Reminder (PDF)
Notice of Privacy Practices - Arabic
Notificación de divulgación a profesional/proveedor fuera de la red
Patient Consent to Draw/Test Blood (PDF)
Patient Financial Responsibility (PDF)
Patient Photograph/Video Information Release Authorization (PDF)
Patient Portal Proxy Authorization (Age 18+)
Patient Portal: FAQs (PDF)
Patient Portal: Flyer (PDF)
Practice & Payment Philosophy (PDF)
Professional/Provider: Out-of-Network Disclosure Notification (PDF)
Recordatorio de Seguro Para Recién Nacidos (PDF)
Restriction of Disclosure to Health Plan (PDF)
SureScripts: Opt-Out (PDF)
Vaccine Administration Record: Consent/Refusal to Vaccinate (PDF)
Vaccine Consent - Spanish

Patient Forms

Vaccine Consent - Turkish
18-year old: ADULTHOOD Letter (PDF)
ABN – Advanced Beneficiary Notice of Noncoverage (Medicare only) (PDF)
ABN – Aviso Anticipado de No Cobertura Para el Beneficiario (Medicare Solamente) (PDF)
ABN - Form Instructions
Advocare Beyfortus Patient Liability Form
Advocare Newborn Insurance Reminder - SPANISH
Authorization for Use & Disclosure of Protected Health Information (PHI) (PDF)
Authorization to Bring a Minor (PDF)
Autorización para el uso y divulgación de información médica protegida (PHI) (PDF)
Cancellation of Prior Health Information Exchange (HIE): Opt-Out (PDF)
Cancellation of Prior SureScripts: Opt-Out (PDF)
Case Registration (PDF)
Estimated Cost: Out-of-Network Services (PDF)
Formulario de responsabilidad financiera del paciente de Advocare
Healow Trifold (PDF)
Health Information Exchange (HIE): FAQs (PDF)
Health Information Exchange (HIE): Opt-Out (PDF)
IMM Withdrawal from NJIIS
Informed Consent: In-Office Procedures (PDF)
Informed Consent: Surgical Procedure or Invasive Treatment Procedure (PDF)
New Jersey Immunization Information System (NJIIS): Consent (PDF)
Newborn Insurance Reminder (PDF)
Notice of Privacy Practices - Arabic
Notificación de divulgación a profesional/proveedor fuera de la red
Patient Consent to Draw/Test Blood (PDF)
Patient Financial Responsibility (PDF)
Patient Photograph/Video Information Release Authorization (PDF)
Patient Portal Proxy Authorization (Age 18+)
Patient Portal: FAQs (PDF)
Patient Portal: Flyer (PDF)
Practice & Payment Philosophy (PDF)
Professional/Provider: Out-of-Network Disclosure Notification (PDF)
Recordatorio de Seguro Para Recién Nacidos (PDF)
Restriction of Disclosure to Health Plan (PDF)
SureScripts: Opt-Out (PDF)
Vaccine Administration Record: Consent/Refusal to Vaccinate (PDF)
Vaccine Consent - Spanish
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