Antietam Pediatric and Adolescent Care
New Patient Intake Form
Authorization for Release of Medical Information (PDF)– Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.
Autorización De HIPAA Para Divulgar Información Del Paciente
Authorization and Consent for Treatment (PDF) – All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.
Autorización y Consentimiento Para el Tratamiento
Preferred Contacts (PDF) – Patients are encouraged to complete and return the Preferred Contacts Form but it is not required.
Contactos Preferidos
