Forms
Records Requests
Records release form for our San Luis Obispo location to send out or receive records from another office. Under HIPAA privacy laws, adult patients (18+) must personally request their medical records. If they wish to release records to a parent or another individual, they must list the recipient as the authorized party.
Records release form for our Templeton location to send out or receive records from another office. Under HIPAA privacy laws, adult patients (18+) must personally request their medical records. If they wish to release records to a parent or another individual, they must list the recipient as the authorized party.
Formulario para la liberación de registros para la ubicación de San Luis Obispo para poder recibir o enviar registros de otra oficina. Los pacientes adultos (mayores de 18 años) deben solicitar sus propios registros. Para divulgar registros a un padre u otra parte, deben incluir al destinatario como la parte autorizada.
Formulario para la liberación de registros para la ubicación de Templeton para poder recibir o enviar registros de otra oficina. Los pacientes adultos (mayores de 18 años) deben solicitar sus propios registros. Para divulgar registros a un padre u otra parte, deben incluir al destinatario como la parte autorizada.
Consent Forms
Permission for Central Coast Pediatrics to treat patient without the presence of a parent or guardian(must be 14 years of age and older)
Permission to give our practitioners and your caretakers the authority to bring your child in and make medical decisions on your behalf.
Permiso para que Central Coast Pediatrics trate al paciente sin la presencia de un padre o tutor (debe tener 14 años de edad o más)
Permiso para dar a nuestros médicos y a sus cuidadores la autoridad para traer a su hijo y tomar decisiones médicas en su nombre.
Confidential Communication Request Form
Submit a confidential communication request form 7 days before your visit. For more about how you can KEEP IT CONFIDENTIAL visit myhealthmyinfo.org
Vanderbilt Assessments
Parent Initial Vanderbilt Assessment Form
Teacher Initial Vanderbilt Assessment Form
Parent Follow Up Vanderbilt Assessment Form
Teacher Follow Up Vanderbilt Assessment Form
