Forms and Policies

• Physician Office Authorization Treatment Form
• Involvement in Care Form
• Healthy Habits Survey
• Ohio – School Medication Form
• Ohio – Child Medical Statement for Child Care Form

You can find the Medical Records Release Form and other forms here.

• Modified Checklist for Autism in Toddlers
• Vanderbilt Parent Initial Assessment
• Vanderbilt Parent Follow-Up Assessment
• Vanderbilt Teacher Initial Assessment
• Vanderbilt Teacher Follow-Up Assessment
• Vanderbilt ADHD Assessment Scale - all forms combined
• Patient Health Questionnaire - 9 (PHQ-9)
• Patient Health Questionnaire - 9 (PHQ-9) - Modified for Teens
• GAD-7 Anxiety Assessment

• Ohio – OHSAA Pre-Participation Evaluation Form
• Indiana - IHSAA Pre-Participation Evaluation Form
• Kentucky - KHSAA Pre-Participation Evaluation Form

• Flu Vaccine Information Sheet (Inactive)
• Flu Vaccine Information Sheet (Live)
• Flu Vaccine Questionnaire

While most insurance plans provide automatic coverage for the 30 days following birth, parents are responsible for adding a newborn to their insurance to ensure coverage after that 30-day period.

• Having a baby is considered a qualifying life event which means you are able to make changes to your health insurance coverage. If your employer offers multiple insurance options, you should research which plan best meets your family's needs.
• Birth certificate and social security number may be required for
• Failure to enroll your baby in an insurance plan within the required timeframe will mean that you are responsible for all costs of your baby's care. This includes immunizations, which can be expensive over time.
• If you don't have insurance through an employer plan, your child may qualify for a government-sponsored plan through Medicaid or the federal or state marketplace.
• If both mother and father have insurance coverage, your child may be covered by both plans if you choose. However, the "Birthday Rule" designates that child's primary coverage follows the parent with the earliest birthday date each year.
• While many plans cover well child visits and immunizations, there may be deductibles, copayments, and coinsurance for which you may be responsible. Check with your insurance provider for details.
• Always consult your insurance provider for specific rules and limitations that may apply.

Ohio law considers people who are 18 years of age or older to be capable of giving valid, legally enforceable consent to receive medical treatment unless the patient has a court-appointed guardian that is currently valid. Generally, patients under age 18 (minors) must have the consent of a biological/adoptive parent or legal guardian before receiving medical care.

You will be required to complete both Involvement in Care and Authorization for Treatment of Child forms. To protect you and your child, we ask that you promptly notify us of changes in parental status as this directly impacts who can make medical decisions and/or access your child's medical record.

TriHealth Pediatrics believes in the safety and effectiveness of vaccines to prevent serious illness and to save lives. Vaccinating children and young adults may be the single most important health-promoting intervention to reduce unnecessary risk for illness, disability, and death.

As such, TriHealth Pediatrics requires all patients to adhere to the Advisory Committee on Immunization Practices (ACIP) and of the Centers for Disease Control (CDC) and American Academy of Pediatrics (AAP) primary series vaccination schedule.

Patients who deviate from this schedule and are not granted an exemption (rare and reviewed on a case-by-case basis) may be discharged from the practice.

All new pediatric patients must provide complete, up-to-date records (vaccination and relevant medical history) before their first appointment. These must be in a format ingestible in our electronic medical record and readable by your care provider. If we do not have this information in advance, your visit must be rescheduled.

We understand that situations may arise making it difficult to keep appointments. To ensure that we can provide care to patients waiting to be seen, it is important that you notify us at least 2 hours in advance if you are unable to keep your scheduled appointment time. Notification within 2 hours or less will result in your appointment being marked as a no-show and a potential charge. Three no-show appointments in a rolling 12-month period could result in discharge from the practice.