St. Augustine Pediatric Associates

Previsitation Forms

Please click on the below link to review and complete required forms prior to each visit. Doing so will save time and effort for both patient and staff members. Thank you.

Medical Records Request Form

If you are requesting medical records from another facility to be sent to St. Augustine Pediatrics Associates

Medical Record Release Form

If you need medical records from our practice, they can be accessed from the patient portal. If you do not have access to our patient portal, please contact our office to request a registration invite. All requests should be sent Attention: Michelle.

PCMH Contract

This is the PCMH Contract of our practice

Transition of Care to Adult Policy

This is the Transition of Care to Adult Policy

Initial NICQH Form(Teacher)

This is the initial form that your child's teacher needs to complete, with ink, and return it to either the parent/guardian or directly to St. Augustine Pediatric Associates.

Follow-up NICQH Form(Teacher)

This is the follow-up form that your child's teacher needs to complete, with ink, and return it to either the parent/guardian or directly to St. Augustine Pediatric Associates.

Medical Proxy Form -*Must be notarized

If you are going out of town and have assigned someone to care for your child/children as well as allow them to make medical decisions in your absence, please complete this form and provide a copy to the caregiver assigned. This will provide legal authorization for providers to treat your child in your absence.