We realize how valuable your time is, so in an effort to decrease the time spent in the office filling out paper work we have made some of our most requested forms available for download. These can be printed and filled out at your convenience prior and brought with you to your next visit.

Patient Form Name   Description

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.