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- Infant Forms
- Missed Appointments
- Office and Patient Encounter Forms
- Retail-based Clinics
- Well Child Forms
 | Four Month Preventive Care Questionnaire
Questionnaire provides key questions to ask at the 4-month preventive care visit. Areas covered are nutrition, sleep, development, elimination, safety, and mother and family issues.
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 | Newborn Follow-Up
Sample form created in 2004 provides key questions, procedures, and documentation for the newborn follow-up visit.
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 | Nine Month Preventive Care Questionnaire
Questionnaire provides key questions to ask at the 9-month preventive care visit. Areas covered are nutrition, sleep, behavior, safety, and mother and family issues.
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 | Sample New Baby Insurance Card
Provides a sample of a "New Baby Insurance Coverage" card for pediatricians to give to families as a reminder to inform insurance carriers of a new baby needing health care coverage.
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 | Six Month Preventive Care Questionnaire
Questionnaire provides key questions to ask at the 6-month preventive care visit. Areas covered are nutrition, sleep, behavior, safety, and mother and family issues.
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 | Two Month Check
Handout provides information to parents on what is covered at the 2-month preventive care visit. It provides detail on what is important regarding the baby's development, nutrition, safety, and immunizations.
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 | Two Month Preventive Care Questionnaire
Questionnaire provides key questions to ask at the 2-month preventive care visit. Areas covered are nutrition, sleep, development, elimination, safety, and mother and family issues.
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 | Missed Appointment Policy
This sample missed appointment policy can be used and/or adapted to meet the needs of your practice.
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 | A Parent’s Guide to Benefits
This sample flyer provides patient families with basic information regarding benefit plans, including well child care policy, adding/dropping dependants, life insurance, and other important topics. To be posted in the pediatric office setting.
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 | Asthma Visit Form
This sample form can be used when caring for children who have asthma.
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 | Billing Form
This form provides a template for tracking care plan management by patient using regularly used CPT codes.
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 | Claim Correction Form
Sample form that includes pre-printed fields typically used when correcting claims submitted to a payer. Includes fields such as plan information, diagnostic codes, CPT codes, and general administrative errors to be corrected.
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 | Co-Payments
This is a sample office document that can be given to parents and guardians who are unable to make a co-payment for their visit.
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 | Consultation Request Form
Sample form provides format with key pieces of information required for an effective referral to specialty care and proper follow-up with the patient.
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 | Developmentally Based Fall Precautions
A sample office checklist outlining precautions to take in order to prevent falls. Over 20 precautions are listed, categorized for infants and for all patients.
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 | Happy New Insurance Year
This sample flyer provides a reminder for patients to review the date their insurance card renews and encourages patients to fully understand co-pays, pharmacy benefits, and referral requirements for their plans. To be posted in the pediatric office setting.
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 | Health Form Policies
This is a sample document that can be given to parents and guardians on the policy for completing school forms.
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 | Illustrations of Situations Requiring/Not Requiring Authorization
Sample list of situations illustrating when your practice must obtain patient authorization to disclose protected health information, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule.
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 | Log to Track Disclosures of PHI
Sample form for practices to track non-TPO disclosures of a patient's protected health information, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule.
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 | Medical Home Care Coordination Measurement Tool
Tool provides ways to collect patient level data on care coordination services provided, the time required to provide the services, the complexity of the patient's needs, and the outcome resulting from the intervention.
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 | Notice of Privacy Practices
Sample office document for Notice of Privacy Practices to post and distribute to patients, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule.
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 | Office Financial Policy
This sample office financial policy can be used and/or adapted to meet the needs of your practice.
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 | Overview of Today's Visit: Sample Form
This sample document can be used by front office staff on all patients upon checking in to ensure that all administrative needs are handled by the appropriate staff and not the pediatrician.
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 | Parental Refusal to Vaccinate Form and Info
This resource includes a cover memo from the Section on Infectious Diseases, which provides background information regarding the Refusal to Vaccinate form; as well as a template Refusal to Vaccinate form that can be modified to suit a practice's needs. Additional resources for pediatricians and parents are also listed.
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 | Patient Complaint Form
Sample form for patients who wish to complain about your practice's privacy policies and procedures, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule.
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 | Patient Survey
This sample document can be used or modified to ask patient's about their satisfaction with their office visit.
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 | Physician Care Management
Tool used to measure physician care plan monitoring activity. Includes fields such as time spent on phone calls, care conferences, reviewing labs, test results, and general care plan oversight.
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 | Pre-Visit Contact Form
This sample form can be filled out by parents in preparation for their child's next office visit.
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 | Privacy Officer’s Incident Event Log
Sample form for the practice's Privacy Officer to track complaints and monitor compliance with the HIPAA Policy Rule, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule.
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 | Receipt of Notice of Privacy Practices Written Acknowledgement Form
Sample form for obtaining written acknowledgment from patients that they have received a copy of the official Notice of Privacy Practices, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule.
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 | Request to Inspect and Copy Protected Health Information
Sample request form for patients who wish to inspect and copy their protected health information, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule.
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 | Sample Privacy Policies
Sample list of privacy policies for developing and implementing policies related to protected health information, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule.
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 | Sample Privacy Procedures
Sample list of privacy procedures to be used for developing and implementing procedures related to protected health information, one of a collection of documents designed to assist your practice in setting up appropriate policies and procedures to comply with the HIPAA Privacy Rule.
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 | Sick Visit Sample
This sample document can be used as a template for sick child visits.
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 | Supplies Needed to Start a Practice
This checklist includes 3 sample lists of the various supplies needed to start a medical practice. Tab 1 outlines the medical office supplies, tab 2 the equipment, and tab 3 the office supplies needed.
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 | The Medical Home Family Index Survey
This is a companion tool to the Medical Home Index: Measuring the Organization and Delivery of Primary Care for Children with Special Health Care Needs and is intended for use with a cohort or families whose children have special health care needs
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 | Tool C: Choices of Billable Telephone Care
This sample checklist can be used to guide discussion among members of your practice to determine which telephone visits would warrant a fee. This is part of the AAP's Payment for Telephone Care: A Toolkit.
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 | Tool G: Sample Office Sign
Sample office sign alerting patients of a new policy for charging for telephone visits. This is part of the AAP's Payment for Telephone Care: A Toolkit.
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 | Tool H: Sample Office Answering Message
Sample language for answering service messages alerting patients of the option of telephone visits as well as potential charges. This is part of the AAP's Payment for Telephone Care: A Toolkit.
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 | Tool I: Sample Staff Scripts
Sample language for staff and pediatrician alerting patients/families of a fee for telephone visits. This is part of the AAP's Payment for Telephone Care: A Toolkit.
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