New Patient Forms
The following documents should be filled and must be presented before your first visit.
- Patient Registration
- Office Policy
- New Patient History
- Authorization to obtain Medical Records
- Authorization for non-biological parents
Please bring the following to your first visit:
- Your Child’s Immunization Records
- Insurance Card
- Caregiver’s Driver License
Well Child Visit Forms by Age:
- WCC birth-4 weeks–1 month
- Well Visit 2 mo
- Well Visit 4 mo
- Well Visit 6 mo
- Well Visit 9 mo
- Well Visit 12 mo
- Well Visit 15 mo
- Well Visit 18 mo
ADHD/Mental Health Initial Evaluation
- Behavior History Form (evaluation for Mental Health)
- Vanderbilt Parent (evaluation for ADHD)
- Vanderbilt Teacher (evaluation for ADHD)
- SCARED Child Version (evaluation for anxiety disorder)
- SCARED Parent Version (evaluation for anxiety disorder)
- PHQ-9 (evaluation for depression)
- YMRS for Mood/Bipolar Disorder Evaluation
If you have concerns that your child might be autistic, please also visit http://www.childbrain.com/pddassess.html. Fill out the ASD Assessment Scale/ Screening Questionnaire, score it, print it out (2 pages) and bring it to your initial visit.
ADHD/Mental Health Follow Up
- Vanderbilt Parent Follow Up (if your child is being treated for ADHD)
- Vanderbilt Teacher Follow Up (if your child is being treated for ADHD)
- PHQ-9 (if your child is being treated for depression)
- SCARED (if your child is being treated for anxiety)
Premier Pediatrics Policy for ADHD management
Premier Pediatrics Discounted/Sliding Fee Policy
It is the policy of Premier Pediatrics to provide essential medical services to all patients, regardless of the patient’s ability to pay. Discounts are offered to those who qualify based upon family/household size and annual income. A sliding fee schedule is used to calculate the basic discount and is updated each year using the Federal Poverty Guidelines. Once the application is approved, the discount will be honored for six months, after which the patient must reapply.
Discount Application Process
To apply for our Sliding Fee Schedule, the patient must provide necessary documentation along with a completed application. The required documentation includes proof of:
- Home Address
- Household Income
- Insurance Coverage
If the applicant appears to be eligible for Medicaid, a written denial of coverage by Medicaid may also be required.
The discount will apply to all services received at this clinic, but not those services purchased from outside, including reference laboratory testing, drugs, and x-ray interpretation by a consulting radiologist, and other such services. This form must be completed every 6 months, or if your financial situation changes.
NOTE: To comply with federal regulations, in order to give you a discount on our medical services, it is necessary for us to ask some personal questions. Your answers will be kept on file and in strict confidence.
Your yearly income tax return, a copy of your W-2 form, last month’s paycheck stubs, copies of your social security checks, or other checks you may receive will be sufficient proof. Your annual income and your family size will be used to calculate your discount.