Forms
Downloadable Forms
Download the forms and fax to 401-725-3188, email to office@northprovidencepediatrics.com or bring with you on the day of your appointment.
Patient Portal
Patient Portal Authorization Form - Download
Required to create an account on our Patient Portal.
Authorization to Exchange Protected Health Information - Download
Required to create an account on our Patient Portal and when transferring health information to and from North Providence Pediatrics.
Health Record Authorization Forms
HIPAA Protected Health Record Release Authorization - Download
Required when transferring health information to and from North Providence Pediatrics.
HIPAA Notice of Privacy Form - Download
Required when transferring health information to and from North Providence Pediatrics.
Patient Screening Forms
PHQ-9 Depression Screening Form - Download
Optional when planning on consultations with North Providence Pediatrics pertaining depression.
M-Chat Autism Screening Checklist - Download
Optional when planning on consultations with North Providence Pediatrics pertaining autism.
ADHD Assessment Scales - Download
Optional when planning on consultations with North Providence Pediatrics pertaining ADHD.
Anxiety Self-Rating Scales - Download
Optional when planning on consultations with North Providence Pediatrics pertaining anxiety.
GAD-7 Anxiety Rating Scales - Download
Optional when planning on consultations with North Providence Pediatrics pertaining anxiety.
School Physicals
Rhode Island School Physicals - Download
Required when planning on consultations with North Providence Pediatrics pertaining school physicals.
Physical Education Nutrition Screening - Download
Required when planning on consultations with North Providence Pediatrics pertaining school physicals.
Physician Orders for Students With Diabetes - Download
Required when planning on consultations with North Providence Pediatrics pertaining students with diabetes.