Forms & Documents

To download the forms and information you need, simply expand each category title and select the form title.

Our offices have transitioned to our new, patient intake process, Phreesia.

Effective 7/19/21

With Phreesia can confirm your appointment via text message or email, and check in online prior to your visit. You can also check in on your own device when you arrive. Ask us about using mobile registration to make your next visit simpler and faster!
Angel Kids Pediatrics is partnering with Phreesia to help you save time registering for your appointment. Use mobile check-in to register from any smartphone, tablet or computer from the privacy of your own home. Checking in on your device saves you time and ensures your information is always up to date!

After scheduling your child’s appointment, you will receive a Text and/or Email with a link to our new (easier) electronic process, Phreesia.

We no longer have  PDF or Printed versions of the New Patient Paperwork Available.

To learn more about our new process, please click here.

Angel Kids Pediatrics Phreesia

If you have NOT received the link via text/email , please contact us and our Customer Service Representatives will confirm your information and resend to you. Click here to call: 904-224-KIDS 5437 option 2

If you are trying to request a Shot and/or Physical Record, you will need to contact the office where you most recent visit was located it. 

PLEASE NOTE: Physical and shot record forms requested after the well-exam visit will incur a charge of $10.00 per set. This fee must be paid in full prior to receiving the completed forms. Angel Kids Pediatrics will not hold the liability of faxing or mailing any forms. Please give us 48-72 hours’ notice when requesting forms so that we have adequate time to prepare them.

To request your records, please click here to call: 904-224-KIDS (5437) Option 2

MEDICAL RECORDS REQUEST

You can also request your medical records from your child’s Patient Portal here.

  • For patients who are transferring out (leaving our practice), please download this medical release form and have their new provider sign the release form. They will then need to fax it back to us.
  • Any medical records request for personal purposes, must download this medical release form, complete and sign the attached form. Then you must fax it back to us. A fee of $1.00 (one dollar US) per page for the first 25 pages and $0.25 (twenty-five cents US) for succeeding pages.

If you need additional assistance regarding this matter, please contact us here:  904-224-KIDS (5437) option 2

You can also request your medical records from your child’s Patient Portal here. If you have not completed your child’s Patient Portal registration, you will need to request a pin here.

  • For patients who are transferring out (leaving our practice), please download this medical release form and have their new provider sign the release form. They will then need to fax it back to us.
  • Any medical records request for personal purposes, must download this medical release form, complete and sign the attached form. Then you must fax it back to us. A fee of $1.00 (one dollar US) per page for the first 25 pages and $0.25 (twenty-five cents US) for succeeding pages. 

If you need additional assistance or have questions regarding your child’s medical records, please contact us at: 904-224-KIDS (5437) option 2

Download and Print: Medical Records Auth to Release Form – 2021

For special forms to be completed, you will be charged $25.00 per form. Physical and shot record forms requested after the well-exam visit will incur a charge of $10.00 per set. This fee must be paid in full prior to receiving the completed forms. Angel Kids Pediatrics will not hold the liability of faxing or mailing any forms. Please give us 48-72 hours’ notice when requesting forms so that we have adequate time to prepare them.

Our patients have the following rights to privacy and respect regarding their personal information:
  • The right to access and copy health records with reasonable notice.
  • The right to request amendment or correction.
  • The right to an accounting of disclosures.
  • The right to specify how confidential information is communicated.
  • The right to request restriction on how health information is disclosed or used.
  • The right to file a compliant if they believe that our safeguards and procedures have not been followed.
  • To view our Patient Non-Discrimination Policy, please click here (PDF)

View Our: INSURANCE AND OTHER PATIENT RESPONSIBLITIES

View Our: CANCELLATION, NO SHOW AND E.R. POLICY

Any privacy issue complaints should be directed to the Privacy Officer. If satisfaction is not received, the patient may notify the Department of Health & Human Services.

In consideration of the services provided to the patient, the parent/guardian is directly and primarily responsible to pay the amount of all charges incurred for services (including laboratory testing and radiology) and procedures rendered at Angel Kids Pediatrics. You are responsible for any applicable deductible, co-insurance or co-payments prior to the provision of services.

Angel Kids Pediatrics may file a claim for payment with my insurance company as required by contractual agreement. If the insurance company fails to pay Angel Kids Pediatrics in a timely manner for any reason, then I understand that I will be responsible for prompt payment of all amounts owed to Angel Kids Pediatrics. Should the account be referred to a collection agency or attorney for collection, the undersigned shall pay all costs of collection, including a reasonable attorney’s fee. The billing department and/or office mangers handle financial matters, not the doctors. Angel Kids Pediatrics will still collect the applicable co-pays, coinsurance, and deductibles at the time of service from the Presenting Guardian. Please direct your questions accordingly. Settlements/financial responsibilities, such as divorce, must be resolved between parents. We do not get involved with these issues.

View Our: PRIVACY POLICY AND FINANCIAL AGREEMENT

It is the parent/guardian’s responsibility to provide Angel Kids Pediatrics with a copy of your child’s current insurance card. If you do not have insurance, you will be considered a Private Pay (or Self Pay) patient and are financially responsible for the total amount of the services provided. You must notify Angel Kids Pediatrics immediately upon any changes with your insurance.

Please be aware, regarding Medicaid, Angel Kids Pediatrics can only accept the State of Florida Medicaid.

View Our: INSURANCE AND OTHER PATIENT RESPONSIBLITIES


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