Patient Information for Registration

 

In order to fast-track your child’s first visit, we ask that you take the time to review and complete the following registration and permission forms. The first three documents register your child with our practice, give us permission to treat, and ask your pediatrician or other specialists who have seen your child to send us your child’s records. The last two documents, denoted as HIPAA, relate to the new federal patient privacy rules which protect information about your child and your family from misuse.  Please print each of these documents and bring them with you to your child’s first appointment. If more convenient, you may fax the registration information and the SIGNED authorization forms to our office at 860-232-2750.  You may reach each form by clicking on its link below.

-- Pediatric Ear, Nose & Throat Associates Registration Form -->Fill out and submit electronically or print
-- Authorization to Treat A Minor Child -->Please read and be prepared to SIGN at the office
-- Medical Record Transfer Request -->Please read and be prepared to SIGN at the office
-- Notice of Our Privacy Practices (HIPAA) -->READ
-- Parental Consent to Privacy Practices (HIPAA) -->Please read and be prepared to SIGN at the office

Printing Hint: If you encounter difficulty printing a page from your browser, make a PDF of that page first and then print the PDF.

 

Thank you for taking the time to complete this process. Please be certain to bring your child's insurance card to your child’s first visit. We are looking forward to meeting you.