Established Patients

A summary of patient's rights and responsibilities, per Florida Statute 381.026

A registration form is required each year to ensure current information is on file.

This registration form is for patients 18 years and older or foster parents and is required each year to obtain current information for patients and parents. 

This form must be completed by the parent or guardian who will be present for office visits. It covers our financial responsibility policies and notice of privacy practices.

For foster parents (patients of any age): this form must be completed by the guardian who will be present for office visits.
For patients 18 years and older: this form must be completed by the patient.

Please fill out this form to have your child's medical records released FROM Pediatric Health Care Alliance to another doctor or medical facility.

Please complete this form to consent to treatment of a minor child, and to identify individuals who may bring your child to the office for treatment. Without this form, we will be unable able to deliver medical service to your child if he or she is accompanied by someone other than the listed parent(s)/legal guardian.

Please fill out this form to allow your parents or anyone else that you have identified access to your medical information.

If you need a copy of your child's medical records for any reason, please review and complete this form and turn it in at your pediatrician's office.

This form contains detailed billing policies and a representative list of items with potential fees and charges, to ensure you are better informed at the time of services and prior to the arrival of a billing statement. A completed form is required each year.

For your convenience, we offer a service to keep your credit card on file for any charges related to office visits and outstanding balances. Please complete this form and bring it to the office at your next visit if you would like to opt-in to this service. 

Starting in early 2023, this statement will be presented to all patients as part of registration. It is our PHCA philosophy regarding the unique challenges and sensitive nature of medical care for children of divorced or separated parents. This is designed to help parents navigate these sensitive areas and avoid misunderstandings during the treatment process.