Email: customerservice@pediatricsoffranklin.com
Fax: (615) 794-2883
For your convenience, new patient forms are available for immediate PDF download or online submission.
Patient Health History – UNDER 3 MONTHS OLD
Consent to Treatment of a Minor When Parents/Guardians Are Temporarily Unavailable
Authorization and Consent for Treatment (PDF)
All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento
To release medical records every doctor’s office needs written permission to do so. Please print your copy, sign your release and email or fax it back to us.
Authorization for Release of Medical Information (PDF)
Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.
Please be sure to download the correct form required by your specific school which may be found on from your child’s school website.
TSSAA Parent History Form (Required before doctor can sign form)
Visit TSSAA.org for all physical forms and concussion information
For children being evaluated for school or behavioral issues and have not been diagnosed with ADHD:
Parent Form (Child NOT on Medicine)
Teacher Form (Child NOT on Medicine)
For children who have already been diagnosed with ADHD and are currently being treated:
Notice of Privacy Practices (PDF) – 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.
Preferred Contacts (PDF) – Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos
Financial Policy (PDF) – This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.
