Established Patients

Checklist

Clinic Policies Checklist and Acknowledgement Form:

This document summarizes the required patient forms.

Patient Registration 

This form requests your address, phone number, emergency contact and insurance information. One registration needs to be completed per household. All minor children that will be patients of Dr. Whittaker should be listed on this form.

Initial History Questionnaire

This provides the doctor with information about your child’s past medical history.

Authorization to Disclose Medical Records 

This allows us to request copies of your child’s previous medical treatment.

Acknowledgment and Consent (HIPAA)

Our office provides a Notice of our Privacy Practices. This form indicates that you have received notice.

Authorization to Treat in the Absence of Parent or Guardian

Complete, sign and return this document if you anticipate that your child may be accompanied to their appointments by someone other than a parent or legal guardian.

Office Policies

This document provides information about our clinic policies. Please acknowledge receipt of this document. Please keep for your records.

Financial Policies

This outlines the clinic expectations for payment and reimbursement based on the type of coverage (if any) your child has. Please acknowledge receipt of this document. Please keep for your records.

Complete List of Clinic Forms

• New Patient Forms Packet
• Financial Policies
• Office Policies
• Pending Insurance Application Agreement
• Self-Pay Agreement
• Established Patient Forms
• ASQ Forms
• Third Party Forms

Please call the clinic at 503-554-0036 with any questions regarding these forms.