New Patient Forms
New patients must provide their insurance card along with the following completed forms prior to the first visit.
- Patient Intake Form (at this time, we are only accepting newborns and new patients with private insurance)
- Intake Form Spanish
- Acknowledgment of Receipt of Privacy Practices
- Form Policy Consent
Medical Records Release
- Authorization for Release of Medical Records TO Pediatric Associates of Conn., PC
- Authorization for Release of Medical Records FROM Pediatric Associates of Conn., PC
If the records are to be mailed, be sure to identify to whom the records are being released, the purpose for the disclosure and allow 30 days to process your request. Per Connecticut law, we may charge you per page plus postage.