New Patient Registration

Completed by parent/guardian to register a new patient with a CCP Practice

South Hills Interim Health Questionnaire
Waterdam Interim Health Questionnaire

Health questionnaire to be completed by parent/guardian prior to their child's appointment at CCP Waterdam or South Hills offices.

Request of Release of PHI (Medical Records) to a CCP Practice

Completed by parent/guardian to request to transfer PHI to a CCP Practice

Request of Release of PHI (Medical Records) to Children's Express Care

Completed by parent/guardian to request to transfer PHI to Children's Express Care

Designated Representative for Medical Consent

Completed by a parent/guardian to authorize another person to seek medical treatment for their child, i.e., grandparent, aunt etc.

Notice of Privacy Practices and Summary

Describes how medical information may be used and disclosed and how you get access to your medical information

Vaccine Information Statements

Vaccine Information Statements (VISs) are information sheets produced by the Centers for Disease Control and Prevention (CDC) that explain to vaccine recipients, their parents, or legal representatives both the benefits and risks of a vaccine.

Request of Release of PHI (Medical Records) from a CCP Location

Completed by parent/guardian to request medical record release from a CCP practice to another physician/practice. Please select from the list of practices below.