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Division of Pediatric Sleep Medicine: Forms
The Pediatric Sleep Center requires all new patients to complete several forms at their first appointment. Some of those forms are below. If you would like, you may download and complete the forms New Patient Forms prior to your visit. Please bring them with you to your appointment.
New Patient Forms
- Notice of Privacy Practices (English | Spanish)
- Consent to Treatment/Acknowledgement of Receipt of Notice of Privacy Practices (for parent/guardian of a minor child) (English | Spanish)
- Consent to Treatment/Acknowledgement of Receipt of Privacy Practices (for adult patients) (English | Spanish)
- Financial Responsibility Statement (English | Spanish)
Additional Consent Forms
- Medical Permission Form (English | Spanish)
- Instructions for Completion of the "Authorization to Use and/or Disclose Protected Health Information" Form (English)
- Authorization to Use and/or Disclose Protected Health Information Form (English | Spanish)
- Instructions for Completion of the "Request to Access and/or Copy Protected Health Information (PHI)" Form (English | Spanish)
- Request to Access and/or Copy Protected Health Information (PHI) Form (English | Spanish)
