Release of Records Forms

Release of SEE Alternatives Peditrics records TO another provider – If you are transferring care to another provider, this form is used to authorize SEE Alternatives Pediatrics to release the information to another provider. The form must be filled out in its entirety and include the practice TO WHICH the records are being faxed. Please include the fax number.

Personal Copy via Encrypted PDF – This form allows you to receive your child’s records via encrypted PDF.  The PDF is password protected, so you must identify a password according to the guidelines on the form.

New Patient Forms

New Patient Packet – This form has registration information, medical history information, as well as policies and procedures for our office. It is fillable and signable electronically, but may also be printed and completedwith handwriting.

Authorization for Release of Records TO SEEAP– This form allows us to request records from your previous providers.

ADHD Evaluations

Initial Evaluations – These forms are for evaluating your child for ADHD for the first time. Please download and complete Parent Initial Vanderbilts (Have Each Parent Complete) AND Teacher Initial Vanderbilt (Have each teacher complete)

Follow Up Visits – These forms are for monitoring progress of treatment and are used for follow up visits. Please download and complete Parent Followup Vanderbilt AND Teacher Followup Vanderbilt.

Other Forms

Authorization for Non-Custodial Caregivers to Consent to Treat – This form lists non-custodial caregivers (relative, nanny, etc) who may bring your child in for care and authorize treatment.

Forms for your Reference

Notice of Privacy Practices– this form describes how your protected health information is protected and utilized.

Vaxcare Notice of Privacy Practices – Vaxcare is a third party company that provides and bills for commercial vaccines. If you have commercial insurance (BCBS, Aetna, United Healthcare, etc), Vaxcare will be doing the billing.

2023 Policy SEEAP Policy Updates – This handout outlines current policies and procedures that we abide by.