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

• Complete the demographics section at the top for the patient
• Section 7: “PM Pediatrics”
• Section 8: the info for the parent or the school/daycare/etc. that the records are being sent or disclosed to
• Section 9(a): check the appropriate box (use other for X-ray copies or report copies)
• Complete sections 10-13 and sign and date (section 13 can read guardian or parent)
Please fax or hand deliver to the office you were seen in

Download (PDF, 41KB)

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)

Credit Card on File Agreement

Please reference our 2018 Financial Process Update for full details.

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 Due to circumstances beyond our control, our Rockville Centre NY office will close at 6pm on June 6. All other offices are fully operational.