Pediatrics, primary care, cumberland, ri, medical, children, rhode island

Patient Forms

Select and download your form from the list below.

When complete, you may fax (401-333-5215), mail, or drop of your form to the office.

Medical Release Form

What is it for?

To release/obtain copies of patient medical records for transfer, legal, medical or personal purposes.

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New Patient Packet

What is it for?

This packet is for new patients to fill out at or before their first appointment. It includes an information sheet, a financial responsibility form, a copy of the HIPPA privacy policy to read and a signature page to acknowledge that the patient/guardian has read and understands the terms of the HIPPA privacy policy.

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Patient Consent Form

What is it for?

For patients' over the age of 18 to sign if they wish to allow certain approved individuals to access their medical information.

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