Patient Forms...

We hope that having these forms accessible on the internet will facilitate your child's care. 
They are divided into 3 categories:  new patient forms, other HIPAA forms, and State
of Maryland & Montgomery County forms.

Additionally, after you have scheduled your first appointment, you will be given a secure
login and password to the Patient Portal to help manage your child's health care at your
own convenience.

Hirsch Pediatrics New Patient Forms
New Patient Form

Please complete this single page form prior to your first visit.  You may bring it with you or fax/e-mail it to us ahead of time.

This short form will only take a few minutes to complete since all of the information about your child's health will be gathered by Dr. Hirsch himself at the first visit. By keeping the registration paperwork as simple as possible, we hope that you will have a more relaxing first visit to the office.

  Transferring Records to Hirsch Pediatrics
 

To transfer your child's health records to Hirsch Pediatrics, you need to complete this form and mail or fax it to your child's current office.  This form is also known as a Request to Inspect and Copy Protected Health Information.  Please note that you may have to call your current practice to see if there is a fee to complete this request.

 

State of Maryland & Montgomery County Forms
(Though these forms are available online for your convenience, you do not need to bring them to your child's appointment as we maintain copies of these forms already completed with your demographic information.)
Montgomery County Public Schools (MCPS) forms

This website contains all of the MCPS forms, including those listed individually below.
Immunization Certificate

Form for recording immunization history.
Maryland State Child Care Health Inventory Form

Form required to participate in most child care centers, nursery schools, and kindergartens.
  Montgomery County Health Inventory Form
 
Form required to participate in most school sports.
  Lead Screening Form
 
Form required for some children depending on zip code.

 

Other HIPAA Forms  
(These forms can give you greater control over information in your child's chart, also known as Protected Health Information or PHI.)
Authorization for Use and Disclosure of PHI

To request that we disclose your child's PHI to another person or group.  This authorization is only valid for 1 year.

Request to Limit and Restrict PHI

To request that a portion of your child's PHI not be made available to any other entity, including other doctor's offices.
Request to Inspect and Copy PHI

To request a copy of your entire child's chart. There is no additional fee to complete this request.
  Request to Correct or Amend PHI
 

To request that a portion of your child's chart be corrected or amended.
HIPAA Privacy Rule and Acknowledgement Form

Click here to learn more about HIPAA.
Authorization to Complete a School, Camp, or Immunization Form

Prior to completing any school or camp from, as required by HIPAA, we need your signed authorization.  You may include on one signed authorization all of the various forms for all of your children.  As required by HIPAA, this authorization is only valid for 1 year and must be resigned each year.  Please note that there is no additional fee to complete these forms.
Authorization for Hirsch Pediatrics to Provide Care in Your Absence

This form allows you to designate other individuals (i.e. grandparent, neighbor, relative, babysitter) to make medical decisions in your absence as well as bring your child to the office for an appointment.
  Transferring Records to Hirsch Pediatrics
 

To transfer your child's health records to Hirsch Pediatrics, you need to complete this form and mail or fax it to your child's current office.  This form is also known as a Request to Inspect and Copy Protected Health Information.  Please note that you may have to call your current practice to see if there is a fee to complete this request.

  Patient Complaint Form
 

We value your feedback.  Please let us know if any individual at Hirsch Pediatrics has provided less than outstanding care or not met your standards in any way.