Forms and Policies

Medical Record Forms  (Medical records may take up to 4 weeks to process)

 

 

Authorization to

release PHI

 

 

 

 

 

 

 

 

Organization and school forms (Allow 7-10 business days for form processing)


 

 

SLPA exam
form General

 

Missouri State
Preschool Form

                       

MSHSAA

 

HIPAA forms and policies

 

                                                                         

Notice Of Privacy                   HIPAA Consent Form             Medical/Financial Information            Medical/Financial

      Practices                                                                              Disclosure Policy                  Info. Disclosure Form                                                                                         

 

General forms and policies

 

                                                                          

 Financial Policy                        Over the Counter                        Over the Counter                    Split Vaccine Charge

                                               Medication Policy                   Medication Request Form

 

                                                                       

No Food In Office                      Over 18 HIPAA                            Parent Vaccine                              16-17 yr Consent

                                              Release & Consent                           Consent                                     to Treat

 

Vaccine Information Sheets (VIS)   Click on the vaccine name

    Hepatitis B           DTaP              Polio                HiB              Prevnar 13         Rotavirus        Meningococcal

    Hepatitis A          MMR              Varicella            Tdap             HPV                  Flu               Pneumovax 23 PPV

Prescription refill request

If there are not any changes to your prescription refill please email the following information: Patient Name, Patient Date Of Birth, Pediatricianís name, Parentís Name, Parentís Phone Number, Pharmacy name and phone number, Medication Name, and Medication strength and dosage. (If there are any changes or this is a new request please call our office during normal business hours)

refill@stlpeds.com to email a Prescription refill request

Immunization/Medical record request

For a medical record or immunization request please email the following information:
Patient Name, Patient Date of Birth, Call Back Number, a Reason of your request, and where you would like us to send the information.

medicalrecords@stlpeds.com to email a medical record or immunization request

You can also call our office during normal business hours or leave a message after hours for any of these requests.

When you send an email transmission, the email is not necessarily secure and is not encrypted. Email transmissions are not necessarily protected from unauthorized access. Sending email is at your own risk. We cannot accept responsibility for your transmission of confidential information or any obligation with respect to that information not submitted over a secure server.