PATIENT

FORMS

NEW PATIENT PACKET FORM

New Patient Packet: Please complete these forms and bring them to your child’s first appointment

Release of Information Request to LaTouche Pediatrics: Please complete this form and submit it to your child’s previous provider(s) in order for us to receive your child’s medical records

ADD/ADHD FORMS

ADD/ADHD Parent Questionnaire: Please complete this form and bring it your child’s ADD/ADHD appointment

Vanderbilt Parent Form: Please complete this form and bring to your child’s ADD/ADHD appointment

Vanderbilt Teacher Form: Please have your child’s teacher complete this form for you to bring to your child’s ADD/ADHD appointment

OVER 18 YEARS OF AGE FORMS

Once patients turn 18 they are legally adults, and so, will need to sign a consent form (pdf) for their parents to have access to their records and make requests on their behalf.

We see patients until they are 22 years old. We encourage our patients who are reaching this milestone to begin the process of establishing care with a provider who specializes in adult care and to request a complete copy of their medical record (pdf).

EXPECTING PARENT FORMS

Prenatal History Form: Please complete this form and bring it along to your prenatal Meet & Greet with our provider’s appointment.

BEHAVIORAL HEALTH FORMS

Forms for your 1st Appointment:

PCL5_Standard_form: Please complete this form and bring it to your child’s Behavioral Health 1st Evaluation Appointment with Andrea Swanson

Alaska Screening Tool : Please complete this form and bring it to your child’s Behavioral Health 1st Evaluation Appointment With Andrea Swanson

Additional Behavioral Health Forms:

SCARED – Parent version: This form is to be completed by the parent for the patient if instructed by a provider.

SCARED – Patient Version: This form is to be completed by the patient if instructed by the provider.

PHQ-9: This form is to be completed by the patient if instructed by the provider.

CONFIDENTIALITY AND PRIVACY

Keeping our patients’ Protected Health Information confidential and secure is a top priority at LaTouche Pediatrics, LLC. We adhere to the guidelines of HIPAA and the HITECH acts. To read our Privacy Policy, click here.

Health eConnect:

HIPAA Policy:

To be sure we provide our patients with the best health care we participate in VacTrAK, Alaska’s immunization information system.

For more details, talk to your health care provider

EXISITING PATIENT FORMS

Consent and Authorization for Treatment of a Minor: Please complete this form if you would like to authorize other adults to bring your child to appointments, make requests, or pick up prescriptions

Consent and Authorization for Patient Over 18: Please complete this form if you are a patient, 18 years old or older, and would like to authorize your parent(s) to make requests, pick up prescriptions, have patient portal access, or have access to your medical records

MULTIMEDIA POLICY

It is the policy of the practice to ensure that we maintain compliance with HIPAA policies which protect the healthcare information of our patients. We ask that no photos, videos, and/or recordings are taken while interacting with our staff. You may ask permission from providers or staff members to take a photo or record healthcare instructions. However, it is the right of our staff to deny your request. Thank you for your cooperation and compliance with the multimedia policy.

LATOUCHE PEDIATRICS

VOTED THE PLATINIUM AWARD

FOR BEST PEDIATRIC PRACTICE

FOR 10 YEARS IN A ROW.

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OUR DEDICATED STAFF

LaTouche Pediatrics is a private provider of pediatric and adolescent medicine in Anchorage and Eagle River, Alaska. LaTouche Pediatrics was established with the aim of providing excellent health care in a warm and professional setting.

Learn More About Our Providers