New Patient Forms

If you have an appointment with Dr. Hanna, this is the paperwork that needs to be printed out, completed and brought to the appointment with you (one set of paper work for each child). This can also be emailed prior to the appointment if it is telemedicine.

 

1) Contract/Consent for Treatment:please print out, read carefully as it covers important information about the practice, including the strict no show policy, fill out/sign last page and bring the entire document to the appointment.

 

2) Authorization to Release Information: please print out a separate one for each person/entity I have permission to communicate with, (ie, pediatric office, therapist) For the part stating "Concerning the period from", please leave blank, as we will fill it out at the appointment.

 

3) Electronic Communication Consent:please print out only one copy and list names of people I have permission to email and fax (ie, you, pediatric office, therapist).    Every person on this list (other than you) will also need the above Authorization to Release Information form filled out.

 

4) Patient info form and HIPAA acknowledgment: please print out and complete both pages (even though I do not file with insurance companies, the insurance information is requested in case I need to work with them in regards to medication coverage if it is indicated).

 

The following forms are for your review. No need to bring to the appointment unless you have a question about them:

1) HIPAA information
2) Notice of privacy practices

 

When you arrive at the office, please have a seat in the waiting room. Our office administrator is in the office 3 days a week from 9-3, therefore she may not be in during your appointment. The paperwork in the waiting room is for the practice with whom I share office space and does not need to be filled out by you.

 

I know this is a lot of paperwork. Please feel free to call or email me with any questions. If you need to change or cancel the appointments, please let me know via an email or phone call at your earliest convenience.

New Patient Paperwork
Dr Hanna New Patient Paperwork.pdf
Adobe Acrobat document [1.3 MB]

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C.A.R.E.

 

Compassionate Attention,

Respectful Empathy