For your convenience the following forms are available for printing and completion. To reduce the paperwork required during your first visit you may fill out the forms below at home, at your convenience, before arriving at our office.
Please complete these forms prior to your first visit.
- Patient Information Sheet
- Patient Information Sheet for Patients 18 Years and Older
- Medical History
- Responsible Party Statement
- RPA Notice of Privacy Practices (HIPAA)
- RPA HIPAA Acknowledgement
- RPA Request for Restriction on Use or Disclosure of Protected Health Information (PHI)
- RPA Parental Authorization to treat a Minor Child
Please keep your patient information up to date.
These forms may be helpful for the treatment of your child in special situations.
- Newborn Screening
- Newborn to 2 months Insurance Waiver
- Lead and TB screening for 12 month well check
- M-CHAT Form – Modified checklist for Autism in Toddlers, completed at the 18- and 24-month checkups
- Nutritional Assessment
If you would like to request an invitation to our Follow My Health Patient Portal, please complete the Invitation Request Form below and return it by fax, postal mail or drop off. For HIPAA purposes, we do not accept forms via e-mail.
To help you request a transfer of your records to another office or clinic, we have provided below a Records Release Form. The blank form may be printed and then filled out by hand. Be sure to sign the form, and we would appreciate knowing the reason for your transfer. The signed form may be brought or mailed to our office to request your records to be transferred. Please allow two weeks for your records transfer request to be processed.
The following forms allow patients who are 18 years of age and older to inform Raleigh Pediatric Associates how they would like their Health Information used and with whom such information can be shared.