Dear Dr. Christina
PM Pediatrics

Patient Forms

For your convenience, we have provided the following patient forms:
• Patient HIPAA Authorization
• Patient Information Disclosure Authorization
• Temporary Guardianship Consent
• Credit Card on File Agreement

Please fill out the forms below as needed and fax or hand deliver to your local office.

Completing the HIPAA Authorization Form

Please fax or hand deliver to the office you were seen in

Download (DOCX, 32KB)

Patient Information Disclosure

Download (PDF, 305KB)

Temporary Guardian Authorization

Please fill out the form below to authorize temporary consent for your child to be seen at PM Pediatrics with an adult other than yourself. Please submit this form to your nearest office along with a copy of your photo ID.

IMPORTANT: This form is valid for one calendar year and must be renewed each year in order to be considered valid.

Download (DOCX, 87KB)