Young Adult Confidentiality / Release Form Page 2
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3Young Adult Updated Information Sheet
Stepping Stone Pediatrics, LLC
Turning 18 is a major milestone for many reasons, one of which is the significant change to your
rights and responsibilities as a patient. We are pleased that you have elected to continue obtaining
your medical care from Stepping Stone Pediatrics. As a legal adult, however, we need you to sign
and complete forms that pertain to your medical care. Please take a few minutes to fill out this form
as completely as you can. This insures that we have your most up to date information. If you have
questions we’ll be glad to help you.
Patient Name: ___________________________
Today’s Date: _________________
Date of Birth: ____________________________
email: _______________________________
Cell Telephone: ___________________________
Primary /Permanent Address: _______________________________________________________________
Street
City
Zip
College Address (if applicable):
____________________________________________________________
Street
City
Zip
Name of College (if applicable) ______________________________________________________
: Local Name: ___________________________, City: ________________, Phone _____________
Pharmacy(s)
College Name: ___________________________, City: ________________, Phone _____________
Notice of Privacy Practices
I, ____________________, have received a copy of Stepping Stone Pediatrics’ notice of privacy practices.
Parent/guardian’s name
_________________________
_________________
Signature of patient
Date
HIPAA Authorizations
By signing this authorization, I authorize Stepping Stone Pediatrics to use and/or disclose certain protected
health information (PHI) about myself for the purposes indicated below. I do not have to sign this authorization
in order to receive treatment from Stepping Stone Pediatrics. In fact, I have the right to refuse to sign this
authorization. I have the right to revoke this authorization in writing except to the extent that the practice has
acted in reliance upon this authorization. My written revocation must be submitted to Stepping Stone
Pediatrics’ Privacy Officer
.
This authorization expires two years after the date it was signed.
School / Camp physical forms: Do you authorize SSP to complete and forward to the appropriate place
school and camp forms as provided to us by you?
‚ Yes I authorize ‚ No, I do not authorize
Signature ________________________
Date ___________
Communications: So you authorize SSP to leave information on your personal cell phone voicemail?
‚ Yes I authorize ‚ No, I do not authorize
Signature ________________________
Date ___________
Please continue on other side -----------------------à
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