When coming into the office, we want all our families to be familiar with our privacy and practice policies. These policies are evaluated annually as a way to protect all parties and as a way to understand how the office operates. We invite all of our families to look them over and if you have any questions or concerns feel free to call or email our office for the Compliance officer or Office manager.
HIPPA Notice of Privacy Practices 2026
Patients Rights & Responsibilities
Many of these forms below are to be completed annually while other's vary by age and appointment type. You may complete these forms ahead of your appointment and return them to the office via portal attachment, fax, or in-person per calendar year.
Office Forms: Misc. Forms:
- Acknowledgement of Privacy Practices Form Food Allergy Action Plan
- ASQ (9mo) Kentucky Immunization Certificate Form
- ASQ (18mo) Ohio Dept. of Job and Family Services
- ASQ (24mo) 2025-26 OHSAA Participation Form
- ASQ (30mo) Vanderbilt Parent
- CRAFT (teenagers) Vanderbilt Parent Follow up
- Edinburgh (post-partum) Vanderbilt Teacher
- Family Medical History (needed for 1st visit) Vanderbilt Teacher Follow up
- GAD-7 Work Permit
- M-CHAT
- Medical Consent Authorization
- Medical Record Release Authorization
- Patient Registration Form
- PHI Attestation Reproductive Health Care
- PHQ-2 (teenagers)
- PHQ-9 (teenagers)
- Preventive + Sick Visit (annually)
- SCARED (Parent and Child forms)
- Telehealth Consent Form
- Teenage Communication Form (age 16+)
