Forms & Policies

ADHD Information Sheet

Guidelines for ADHD Scheduling

Pediatric Associates Stimulant (ADHD Medication) Agreement

Required form for ADHD stimulant medications.

Parent-Initial

Parent Initial Assessment for ADHD

Teacher-Initial

Teacher Initial Assessment for ADHD

COVID Consent Form

Financial Policy

New patients must review and acknowledge this form.

HIPPA and Financial Policy Signature

Please sign this form and bring it into the office at your first visit

Billing FAQ

Find answers to your FAQs on Billing here

Flu Vaccine Consent Form

Foster Parent Letter of Understanding

Please fill out this form for any new foster children you are caring for.

Notice of Privacy Practices (HIPPA 2013)

This form shows how we use and secure your protected health information (PHI). It must be reviewed and signed by new patients.

18 Years and Older PHI Consent

All patients 18 years and older need to fill this out so we have permission to release records and talk to their designated family members. This includes access to the portal.

Records Release Form

Please fill this out to get records from outside physicians, clinics, hospitals and school psychologists.

Consent to Treat Form

Use this form if you need to give consent to another adult to care for your child when you are unavailable.

KHSAA High School Physical Sports Form

Print and fill out if your child plays high school sports in Kentucky. If they have had a well visit in the last 12months, we can fill it out based on that visit. If it has been more than 12 months since their well visit, please call to schedule and we can fill it out at their visit.

KHSAA Middle School Physical Sports Form

Print and fill out if your child plays middle school sports in Kentucky. If they have had a well visit in the last 12months, we can fill it out based on that visit. If it has been more than 12 months since their well visit, please call to schedule and we can fill it out at their visit.

Ohio High School Physical Sports Form

Print and fill out if your child plays high school sports in Ohio. If they have had a well visit in the last 12months, we can fill it out based on that visit. If it has been more than 12 months since their well visit, please call to schedule and we can fill it out at their visit.

IN High School Sports PE Form (2020-21)

Print and fill out pages 1-2 for your high school student playing sports in Indiana. If they have had a well visit in the last 12months, we can fill it out based on that visit. If it has been more than 12 months since their well visit, please call to schedule and we can fill it out at their visit.

KMA KHSAA COVID Return to Play

The Kentucky High School Athletic Association along with the Kentucky Medical Association has updated their guidance on returning to sports after COVID 19 infection, with the potential reduction of isolation from 10 days to 5. The easiest way to count this is: Day 0 is the first day symptoms occurred or a positive test if asymptomatic. Day 5 is the last day of isolation. Day 6 is the first day that the athlete could potentially return. Athletes also cannot be cleared to return in KY unt...

• We firmly believe in the effectiveness of vaccines to prevent serious illness and to save lives.
• We firmly believe in the safety of our vaccines.
• We firmly believe that all children and young adults should receive all of the recommended vaccines according to the schedule published by the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP).
• We firmly believe, based on all available literature, evidence, and current studies, that vaccines do not cause autism or other developmental disabilities.
• We firmly believe that thimerosal, a preservative that has been in vaccines for decades and remains in some vaccines, does not cause autism or other developmental disabilities.
• We firmly believe that vaccinating children and young adults may be the single most important health promoting intervention we perform as health care providers, and that you can support as parents/caregivers.

The recommended vaccines and the schedule of administration are the results of years and years of scientific study and data-gathering on millions of children by thousands of our brightest scientists and physicians.

The vaccine campaign is truly a victim of its own success. It is precisely because vaccines are so effective at preventing illness that we are even discussing whether or not they should be given. Because of vaccines, many of you have never seen a child with polio, tetanus, whooping cough, bacterial meningitis, or even chickenpox, or known a friend or family member whose child died of one of these diseases. Such success can make us complacent about vaccinating.  Once enough people stop vaccinating, communities are susceptible to a return of these diseases.

In the past, some people in Europe have chosen not to vaccinate their children with the MMR (measles, mumps, rubella) vaccine after publication of an unfounded suspicion (later retracted) that the vaccine caused autism. As a result of under-immunization, there have been small outbreaks of measles and several deaths from complications of measles. The United States experienced a record number of measles cases during 2019, with 1282 cases from 31 states reported to CDC's National Center for Immunization and Respiratory Diseases (NCIRD). This is the greatest number of cases since measles elimination was documented in the U.S. in 2000.

As medical professionals, we feel very strongly that vaccinating children on schedule with currently available vaccines is absolutely the right thing to do for all children and young adults. We are making you aware of these facts not to scare you or coerce you, but to emphasize the importance of vaccinating your child. We are more than willing to discuss any questions you may have about vaccines, but do require all new patients to our practice to adhere to the vaccination schedule required by the state of Kentucky.  If you do not want your child vaccinated, we ask that you not join (leave) the practice.  We do not grant religious exemptions.