Northpoint Pediatrics
Forms
PLEASE NOTE: Health forms require reporting of current health information, so your child or adolescent must have had a well checkup within the last 12 months.
NORTHPOINT FORMS
Various forms you may need for your child's healthcare are found under this section from treatment authorization to release of records forms.
- Benefit Verification Worksheet
- Patient Registration Forms
- Parental Consent Form
- Release of Records - Incoming
- Release of Records - Outgoing
- 18YR and Older Patients - Authorization for Release of Protected Health Information
Fax: 317.621.9190
Email: NPfrontoffice@ecommunity.com
ATHLETIC | CAMP | DAYCARE FORMS
For your convenience, we offer common local athletic, camp and daycare forms below. Please download, print, and bring with you for your child's examination.
There is a $5 service fee to complete athletic, camp and daycare forms. Insurance companies do not provide a benefit for completing medical forms, so we do require payment when the service is requested.
- IHSAA Participation Form
- CYO Participation Form
- Child Care Center Health Record
- Boy Scout Annual Health and Medical Record
What can we do better?
Parent feedback helps us do our work better. Let us know about your child's experience and feedback. Email Linda Kortanek at lkortanek@ecommunity.com.
