Forms & Notices

Here is a list of our forms. You can save time during your visit by reviewing this list and bringing in the form already filled out. If you are bringing your child in for an annual well visit, for example, please review our Well Visit Assessment forms, download the form corresponding to your child’s age, print it, fill it out and bring it with you to your visit. Pediatric Associates will continue to bring the best possible healthcare service to its patients well into the 21st Century. Ease of access, prompt courteous service and responsiveness to our patients’ concerns will always be our primary goal. We realize that patients are the reason we exist and we strive to treat them professionally with compassion, respect and dignity.

Download Patient Forms

pdf-icon Below are general forms available to download. To view the forms listed below, you will need Adobe Reader.

You can download Adobe Reader here.

Save time during your child’s well visit by downloading the form that corresponds with your child’s age/ well visit, fill it out and bring it with you to your visit.

Form Well Visit
Anemia / Lead Risk Assessment Anemia: 4 months, 18 months, annually at well visits between 3 – 18 years
Lead: 6 months, 9 months, 18 months, and all well visits from 3 – 6 years
TB (Tuberculosis) / Cholesterol Risk Assessment TB: 1 month, 6 months, 12 months, 18 months, annually at well visits between 2 years -18 years
Cholesterol: 2 years, 4 years, 6 years, 8 years and annually at well visits between 10 -18 years
Rheumatology Childhood Health Assessment Only use if your child is scheduled with Dr. Kristina Wiers-Shamir
Rheumatology Patient Questionnaire Only use if your child is scheduled with Dr. Kristina Wiers-Shamir

Medicaid Area Office Contact Information:

BROWARD COUNTY
MEDICAID AREA 10 OFFICE
954-202-3200

Complaints and grievances regarding Medicaid and Medicaid HMO’s should be directed to the following:
Agency for Health Care Administration, Department of Insurance Consumer Service Helpline
HMO Hotline 800-342-2762
800-419-3456 200 East Gaines Street,
2727 Mahan Drive, OR Larson Building,
Building 1-Mail Stop #27, Tallahassee, FL 32399
Tallahassee, FL 32308

MIAMI-DADE COUNTY
MEDICAID AREA 11 OFFICE
305-593-3000

Complaints and grievances regarding Medicaid and Medicaid HMO’s should be directed to the following:
Agency for Health Care Administration, Department of Insurance Consumer Service Helpline
HMO Hotline 800-342-2762
800-419-3456 200 East Gaines Street,
2727 Mahan Drive, OR Larson Building,
Building 1-Mail Stop #27, Tallahassee, FL 32399
Tallahassee, FL 32308

PALM BEACH / ST. LUCIE COUNTIES
MEDICAID AREA 9 OFFICE
561-616-5255

Complaints and grievances regarding Medicaid and Medicaid HMO’s should be directed to the following:
Agency for Health Care Administration, Department of Insurance Consumer Service Helpline
HMO Hotline 800-342-2762
800-419-3456 200 East Gaines Street,
2727 Mahan Drive, OR Larson Building,
Building 1-Mail Stop #27, Tallahassee, FL 32399

HILLSBOROUGH COUNTY
MEDICAID AREA 6 OFFICE
813-350-4800

Complaints and grievances regarding Medicaid and Medicaid HMO’s should be directed to the following:
Agency for Health Care Administration, Department of Insurance Consumer Service Helpline
HMO Hotline 800-342-2762
800-419-3456 200 East Gaines Street,
2727 Mahan Drive, OR Larson Building,
Building 1-Mail Stop #27, Tallahassee, FL 32399
Tallahassee, FL 32308

DUVAL COUNTY
MEDICAID AREA 4 OFFICE
904-798-4200

Complaints and grievances regarding Medicaid and Medicaid HMO’s should be directed to the following:
Agency for Health Care Administration, Department of Insurance Consumer Service Helpline
HMO Hotline 800-342-2762
800-419-3456 200 East Gaines Street,
2727 Mahan Drive, OR Larson Building,
Building 1-Mail Stop #27, Tallahassee, FL 32399
Tallahassee, FL 32308