Forms & Policies

If you are new to our practice, prior to your visit, please download, print and complete the top five forms (or all forms are available in this packaged file by clicking here). Please note, it is not necessary to print the Notice of Privacy Practices but please read it prior to your visit.

You will need Adobe Adobe Reader to view and print these forms. Click here to download it now.

WARNING: Filling out the form in the browser will not save the data. The PDF must be opened and filled out in Acrobat, and if using the free Acrobat Reader, must be saved in this method.

New Patient Information/Registration Form
Family Medical History
Financial Policy
Office Policies
Acknowledgement Form for Notice of Privacy Practices
Notice of Privacy Practices
Authorization for Use and Disclosure of Personal Health Information (PHI)
Fees for Forms and Medical Records
Medical Records Release Form (Incoming or Outgoing)
A Patient's Guide to Understanding Health Insurance Coverage and Payment Practices
Office Hours, Addresses, Telephone and Fax Numbers
Over 18 Patient Responsibility Agreement


ADHD Vanderbilt Forms Package
ADHD Vanderbilt Initial Parent Evaluation Forms
ADHD Vanderbilt Initial Teacher Evaluation Forms
ADHD Vanderbilt Parent/Teacher Follow-Up Forms

School Physical Forms

Tri-County Pediatrics

Like Us on Facebook

Business Office: 1939 Cheltenham Avenue, Elkins Park, PA 19027 Offices: See All Locations Email: info@tricountypeds.com

©Copyright 2017, Tri-County Pediatrics. All rights reserved. | Design by Asenka