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Forms & Policies
Many of our forms are available to complete electronically or have a pdf option - see below for the different forms available. Please contact our office at (208) 772-8940 with any questions on completing the forms
Please Allow 10 to 15 business days for completion.
Any applicable fees must be collected before completed request will be provided.
If you are needing form/letter/records sooner, an expedite fee can be paid with a guarantee of no more than 5-7 days completion.
Would you like an easy way to communicate with us securely and have the ability to access your/your child's information?
Request to gain access to the patient portal by completing the electronic form below. This will allow you to view a medical summary including individual visit summaries, request prescription refills, ask the Provider/Nurse team questions, request appointments, and so much more.
New Patient Forms
We have moved to an electronic registration system for gathering all new patient information. New patients will receive an email in advance of their appointment from cdapeds@checkinasyst.com with a link for pre-registration. If you are unable to complete this pre-registration ahead of time, please be sure to arrive at least 15 minutes before your appointment time to complete the registration process in the office. Please call our office if you have any further questions regarding this process.
Release of Information Forms
- Authorization to Release Medical Information TO Coeur d'Alene Pediatrics
- Printable PDF
- Authorization to Release Medical Information FROM Coeur d'Alene Pediatrics
- Patient Authorization to Release Medical Information TO Third Parties
School Sports Physical Form
Boy Scouts Physical Form
Girl Scouts Physical Form
Request for Letter/Forms or For Provider's Signature
- Form/Letter Completion Request
- Emotional Support Animal Request
Request for FMLA paperwork
Billing Forms
- Accepting Financial Responsibility
- Relinquishing Financial Responsibility
- Financial Hardship or Balance Dispute
Notice of Privacy Practices
Vaccine Policy
Coeur d’Alene Pediatrics is dedicated to the well-being of all children, adolescents and young adults.
Vaccinations are the cornerstone of health and wellness.
The family of providers at Coeur d’Alene Pediatrics firmly believe in the effectiveness of vaccines to prevent serious illness and to save lives.
We also believe in the safety of our vaccines.
We feel strongly that all children and young adults should receive all of the recommended vaccines according to the schedule published by the Centers for Disease Control and the American Academy of Pediatrics.
We also believe – based on all available literature, evidence and current studies – that vaccines do not cause autism or other developmental disabilities.
We believe that vaccinating children and young adults may be the single most important health- promoting intervention we perform as health care providers and that you can perform as parents/caregivers. The recommended vaccines and the schedule by which they are given are the result of years and years of scientific study and data gathered on millions of children by thousands of our brightest scientists and physicians.
These things being said, we recognize that there has always been-and will likely always be-controversy surrounding vaccinations. Indeed, Benjamin Franklin, persuaded by his brother, was opposed to the smallpox vaccine until scientific data convinced him otherwise. Tragically, he had delayed inoculating his favorite son, Franky, who contracted smallpox and died at the age of four leaving Ben with a lifetime of guilt and remorse. Quoting Mr. Franklin’s autobiography:
“In 1736, I lost one of my sons, a fine boy of four years old, by the smallpox…I long regretted bitterly and still regret that I had not given it to him by inoculation. This I mention for the sake of parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it, my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen.”
The vaccine campaign is truly a victim of its own success. It is precisely because vaccines are so effective at preventing illness that we are even discussing whether or not they should be given. Because of vaccines, many parents have never seen a child with polio, tetanus, whooping cough, bacterial meningitis or even chickenpox. Most people have not known a friend or family member whose child has Page 2 died of one of these diseases. Such success can make us complacent or even lazy about vaccinating. With such attitude becoming widespread, it can only lead to tragic results. As a result of under-immunization, there have been outbreaks of vaccine-preventable diseases. In 2008, the United States recently suffered the largest measles outbreak in over 10 years, all due to under immunization. In 2008 and 2009, haemophlius influenza type B (Hib), a vaccine-preventable disease, caused numerous cases of meningitis unimmunized infants.
We are making you aware of these facts, not to scare you, but to emphasize the importance of vaccinating your child. We recognize that the choice may be a very emotional one for some parents. We will do everything we can to convince you that vaccinating according to the schedule is the right thing to do; however, should you have doubts, please discuss these concerns with your health care provider. In some cases, we may alter the schedule to accommodate parental concerns or reservations. Please be advised, however, that delaying or “breaking up the vaccines” to give one or two at a time over two or more visits goes against expert recommendations and can put your child at risk for serious illness or death, as well as, goes against our medical advice as providers at Coeur d’Alene Pediatrics. If you decided to follow an alternative vaccination schedule, such additional visits many require additional co-pays on your part. Furthermore, please realize that you will be required to sign a “Refusal to Vaccinate” acknowledgement if vaccinations are delayed or declined.
As medical professionals, we feel very strongly that vaccinating children on the schedule with currently available vaccines is absolutely the right thing to do for all children and young adults. Thank you for your time in reading this policy. Please feel free to discuss any questions or concerns you may have about vaccines with any one of us.
Sincerely,
The Medical Staff at Coeur d’Alene Pediatrics
No Show Policy
No Show appointments, without cancellation or rescheduling in advance, prevent us from providing for the healthcare needs of our patients. An account with 3 or more No Shows in a 12-month period will be placed on restricted scheduling as follows:
1) No longer able to schedule siblings on the same day.
2) Unable to schedule in prime timeslots (such as first thing in A.M. or lunch time hours).
3) Confirmation must be received within 24 hours of the appointment, or the appointment will be canceled as of 8am on the day of even if confirmation was completed prior to the 24 hours.
Restricted scheduling will be lifted if there are no new No Show occurrences within a 1-year time span. If a family or individual continues to miss appointments without advanced notice, they will be dismissed from care in our office.
As always, your healthcare needs are our priority and we wish to continue providing quality care for all of our families.
Consent for Treatment
Electonic Form Submission: https://form.jotform.com/242177365550054
or
Printable PDF: CONSENT-FOR-TREATMENT_-UNEMANCIPATED-MINOR.pdf
School Medication Forms
