Urology
Notice of Privacy Practices Form
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This form acknowledges that you understand that Children’s Hospital Boston complies to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) legislation, which ensures security and privacy of an individual's medical records. Please bring the completed and signed sheet with to your child’s initial visit to the Department of Urology, if it is your first visit at Children's Hospital Boston.
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When should patients/guardians complete this form?
Every patient/ guardian must fill out this form the first time they visit Children's Hospital Boston.
Urology Patient/Guardian Questionnaire
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This double sided form informs your clinician of your child’s medical history which is imperative to the initial evaluation of your child. Please bring the completed and signed sheet with you during your child’s initial visit to the Department of Urology.
When should patients/guardians complete this form?
Complete this form if it is your child’s first visit to the Department of Urology, or if you haven’t been seen in the Department of Urology in more than 3 years.
Special Instructions:
Under the “Medical History” section on page 2, if the diagnosis’s do not apply, please check the ‘normal’ box.
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Medication History Worksheet
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Please bring the completed sheet with you each time your child visits the Department of Urology.
When should patients/guardians complete this form?
Complete each time your child visits the Department of Urology if either of the following applies to your child:
- Has any known allergies to food or medication
- Takes any medications
Authorization to Release Information and Assign Insurance Benefits
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The release form states that you understand that along with your insurance company, you are financially responsible for today’s appointment. Please bring the signed sheet with you each time your child visits the Department of Urology.
When should patients/guardians complete this form?
Complete each time your child visits the Department of Urology
