RDV Sportsplex Pediatrics
  • Home
  • Our Office
    • Contact Us >
      • Location
      • Send an E-mail
    • Mission
    • Meet Our Providers
    • Meet Our Staff
    • Services Offered
    • Inside Tour
    • Top Doctors
    • Holiday Hours
    • Student Preceptor Application
  • New Patients
    • Become a new Patient
    • New Patient Forms
    • Insurances Accepted
    • Prenatal/Meet-and-Greet RSVP
  • Our Patients
    • Referrals
    • Forms Index
    • Additional Patient Handouts
    • Request/Send Us a Form
    • Records Request
    • Helpful Resources >
      • During Office Hours
      • After Office Hours
      • Family Resources
      • Common Forms and Handouts
      • Vaccines Video Series
  • Billing
    • Billing FAQ
  • Patient Portal

Forms Index 


English

​HIPAA AUTHORIZATION TO RELEASE PATIENT INFORMATION  
Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. 
​Authorization and Consent to Treatment  -
All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. 
​Preferred Contacts  
Patients are encouraged to complete and return the Preferred Contacts Form but it is not required.
​FINANCIAL POLICY  
This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations. 
Notice of Privacy Practices   
​
Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully​

Additional Patient Forms in English

Vanderbilt Forms 
This form, the Vanderbilt Parent Assessment Scale, helps us understand your child's behavior and development.​
Vanderbilt Forms for Teachers
This form is for the teacher, and helps us understand your child's behavior and development.​

Spanish

​AUTORIZACIÓN DE HIPAA PARA DIVULGAR INFORMACIÓN DEL PACIENTE  
Permite a los pacientes autorizar la divulgación de su información médica a un individuo, compañía, agencia o centro designado.​
​AUTORIZACIÓN Y CONSENTIMIENTO PARA TRATAMIENTO
Todos los pacientes deben dar su consentimiento para el tratamiento, las comunicaciones (llamadas, correos electrónicos y mensajes de texto) y la aceptación de la responsabilidad financiera.
​Contactos preferidos
Se anima a los pacientes a completar y devolver el Formulario de Contactos Preferidos, pero no es obligatorio.
POLÍTICA FINANCIERA  
Este formulario notifica a los pacientes sobre su completa responsabilidad financiera por todos los servicios médicos recibidos, independientemente de la elegibilidad del seguro o las determinaciones de cobertura.
Aviso de prácticas de privacidad 
​
Describe cómo la información de salud sobre usted (como paciente de este Centro de Atención) puede ser usada y divulgada, y cómo puede acceder a su información de salud individualmente identificable. Por favor, revise este aviso cuidadosamente.

Other Forms 

1 Month / 2 Month / 4 Month

6 Month

Picture
Picture

9 Month

18 Month

Picture
Picture
Picture
Picture


24 Month

30 Month

Picture
Picture
Picture


3 year

4 year

Picture
Picture

5 year

6 year

Picture
Picture

Graded Concussion Symptom Checklist

Picture
Physician (MD/DO) Recommended School Accommodations Following Concussion Form


​Notice of Nondiscrimination
​Press Room
Notification of Privacy Practice
​Prospective Doctors

Picture

Phone # 407-916-4520
Fax # 407-916-4525
Email: [email protected]
8701 Maitland Summit Blvd., Orlando, Florida 32810
Picture
Facebook
Instagram
Located at
Picture
Design by DivTag Templates
UA-77455288-1