Forms and Policies

• Physician Office Authorization Treatment Form
• Involvement in Care Form
• Healthy Habits Survey
• Ohio – School Medication Form
• Ohio – Child Medical Statement for Child Care Form

You can find the Medical Records Release Form and other forms here.

• Modified Checklist for Autism in Toddlers
• Vanderbilt Parent Initial Assessment
• Vanderbilt Parent Follow-Up Assessment
• Vanderbilt Teacher Initial Assessment
• Vanderbilt Teacher Follow-Up Assessment
• Vanderbilt ADHD Assessment Scale - all forms combined
• Patient Health Questionnaire - 9 (PHQ-9)
• Patient Health Questionnaire - 9 (PHQ-9) - Modified for Teens
• GAD-7 Anxiety Assessment

Direct links to the most updated, required pre-participation/evaluation forms for high school student athletes for Ohio, Indiana and Kentucky. English and Spanish versions available.

• Ohio – OHSAA Website
• Indiana - IHSAA Website
• Kentucky - KHSAA Website

• Flu Vaccine Information Sheet (Inactive)
• Flu Vaccine Information Sheet (Live)
• Flu Vaccine Questionnaire

While most insurance plans provide automatic coverage for the 30 days following birth, parents are responsible for adding a newborn to their insurance to ensure coverage after that 30-day period.

• Having a baby is considered a qualifying life event which means you are able to make changes to your health insurance coverage. If your employer offers multiple insurance options, you should research which plan best meets your family's needs.
• Birth certificate and social security number may be required for
• Failure to enroll your baby in an insurance plan within the required timeframe will mean that you are responsible for all costs of your baby's care. This includes immunizations, which can be expensive over time.
• If you don't have insurance through an employer plan, your child may qualify for a government-sponsored plan through Medicaid or the federal or state marketplace.
• If both mother and father have insurance coverage, your child may be covered by both plans if you choose. However, the "Birthday Rule" designates that child's primary coverage follows the parent with the earliest birthday date each year.
• While many plans cover well child visits and immunizations, there may be deductibles, copayments, and coinsurance for which you may be responsible. Check with your insurance provider for details.
• Always consult your insurance provider for specific rules and limitations that may apply.

Ohio law considers people who are 18 years of age or older to be capable of giving valid, legally enforceable consent to receive medical treatment unless the patient has a court-appointed guardian that is currently valid. Generally, patients under age 18 (minors) must have the consent of a biological/adoptive parent or legal guardian before receiving medical care.

You will be required to complete both Involvement in Care and Authorization for Treatment of Child forms. To protect you and your child, we ask that you promptly notify us of changes in parental status as this directly impacts who can make medical decisions and/or access your child's medical record.

General Consent Form ⤓

Effective Date: February 9, 2026

Scope: This policy applies to all patients receiving care within the practice and to all clinical staff involved in preventive care delivery.

TriHealth Pediatrics is committed to delivering preventive care that reflects the highest standards of pediatric medicine and the best available scientific evidence. We believe:

• In the safety and effectiveness of vaccines to prevent serious illness and to save lives.
• That vaccinating children and young adults may be the single most important health-promoting intervention performed by health care providers and parents/caregivers.
• That by not vaccinating, children are put at unnecessary risk for illness, disability and death.

TriHealth Pediatrics follow immunization guidance developed by national pediatric experts, informed by rigorous scientific review, ongoing safety monitoring, and child-specific clinical expertise. These recommendations are designed to protect individual patients, families, and the broader community.

Because vaccines are part of science based medicine, all patients are expected to meet the nationally recognized minimum immunization requirements for childhood vaccination in the United States as a condition of care. This includes, but is not limited to, the following: DTaP, Polio, Hib, Pneumococcal, MMR, Varicella.

We recognize that families may have concerns regarding immunizations. Our clinicians and staff are always available to answer questions and committed to respectful, evidence-based discussions and shared decision-making when appropriate. Requests for vaccine deferral or delay are reviewed on an individual basis and documented in the medical record. If a child is not vaccinated on the recommended schedule, additional protocols will be in place to maintain the health and safety of all our patients. Patients refusing to vaccinate may be discharged from the practice.

We understand that situations may arise making it difficult to keep appointments. To ensure that we can provide care to patients waiting to be seen, it is important that you notify us at least 2 hours in advance if you are unable to keep your scheduled appointment time. Notification within 2 hours or less will result in your appointment being marked as a no-show and a potential charge. Three no-show appointments in a rolling 12-month period could result in discharge from the practice.

Pediatrics No Show Policy ⤓