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New Patients

Please request your medical records be sent to our office prior to your 1st visit.

   If you are transferring from another pediatric practice, we will need to review a copy of your child’s medical records.

  Please contact your current primary care physician and ask for a copy of your child’s medical records to be sent to our office or you may drop them off. It is important that we have your child’s records prior to your 1st scheduled visit.

New Patients:

Please Fill and Read ALL Forms below.

Thank you

“We accept most Health Insurance Plans”

Call us at: (305) 599-8022

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Please Fill and Read New Patient Information Forms

Patient Information Form

  • Parent / Legal Guardian Information (Please provide I.D.)

  • Alternate Contact

  • Insurance Information (Please provide insurance card)

  • Financial Responsibility Agreement

  • hereby authorize Healthy Kidz Pediatrics and Maria Granados, MD to administer immunizations and/or medical treatment to my child. I also hereby authorize the payment of benefits on my insurance policy, if any, to be paid directly to Healthy Kidz Pediatrics and Maria Granados, MD for services rendered. I further authorize the release of any medical information required by my insurance carrier. I understand that I am financially responsible for charges not paid by my insurance carrier. I also acknowledge receipt of the Notice of Privacy Practices and the “Welcome to Our Practice” flyer, which contains important information regarding the practice’s policies.
  • 9615 N.W. 41st Street Doral, FL 33178
 

Verification

Notice of Privacy Practices

  • * Obtain your written authorization to use or disclose your health information for reasons other than those listed above and permitted under law. We may change our policies at any time. Before we make a significant change in our policies , we will make the new provisions effective for all protected health information it maintains. Revised notices will be made to you at your next appointment after the change. Complaints: You may complain to us or to the US Department of Healthy and Human Services if you believe your privacy rights have been violated. You will not be retaliated against for filling a complaint:
  • By signing this document I acknowledge that I have received a copy of Healthy Kidz Pediatrics Notice of Privacy Practices. I understand that you need this record to provide me with quality care and to comply with certain legal requirement. I also understand that you may use disclose my medical information for your health care operation in order to provide me with the highest level of medical care.
  • Healthy Kidz Pediatrics USE ONLY

 

Verification

Authorization For Release of Confidential Medical Information

  • Healthy Kidz Pediatrics 9615 N.W. 41st Street Doral, FL 33178 Phone: 305-599-8022 Fax: 305-599-8023
  • I understand that I have the right to withdraw my authorization at any time except to the extent that action has already been taken in accordance to the authorization. I understand that if I wish to revoke this authorization, I must do in writing and present my written revocation to a member of the office staff.
 

Verification

 

Patient History

    SOCIAL HISTORY

  • FAMILY HISTORY

  • PREGNANCY AND BIRTH HISTORY

  • PAST MEDICAL HISTORY

 

Verification

 

 

 

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