Forms & Downloads

Need us to complete a form? No problem!

To expedite your request and ensure your form is routed properly, please review the following instructions:

 

We can complete many requests for form completion through email if the date of your child’s well check is within one year.  If you are not sure the date of your child’s last well check, please call the office – we can check for you.

 

If you are requesting  a driver’s license form, please be advised the Pennsylvania Department of Motor Vehicles requires a well check within six months of the child’s 16th birthday. You may submit your request through email, but the Department of Motor Vehicles requires the child to sign the form in the presence of a Healthy Steps staff member, so those forms need to be picked up in our office by the patient.

Where to send your requests:

Please send requests to  hspforms@protonmail.com  if the form requires a doctor’s signature. This may include PIAA forms, school physical forms, or college forms.  Please allow 7 business days for form completion.

Please send requests to  jen@christinemeyermd.com  for records transfer requests and to send records from other sources.

Forms for download:

New Patient Forms

PDF

New Patient

Intake

Form (PDF)

Are you a new patient? Welcome! Download, complete, and bring along this form to your first visit to save some time in the waiting room.

 

Must be completed by an adult over the age of 18, or a parent or guardian of a child under age 18.

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PDF

This form must be completed in order for us to process a claim through your worker's compensation or motor vehicle insurance company.

HIPAA Privacy Forms

PDF

HIPAA Notice of Privacy Form (PDF)

All Healthy Steps patients must have this form on file; please download and bring it to your first appointment, or you can fill it out when you arrive.

 

Must be completed by an adult over the age of 18, or a parent or guardian of a child under age 18.

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PDF

The NICHQ Vanderbilt Assessment Scales are used to help diagnose ADHD in children between the ages of 6 and 12 years.

Transfer to HSP

PDF

Are you transferring practices? Complete this form to authorize our practice to obtain or transfer your medical records to/from another doctor.

 

Must be completed by an adult over the age of 18, or a parent or guardian of a child under age 18.

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PDF

The NICHQ Vanderbilt Assessment Scales are used to help diagnose ADHD in children between the ages of 6 and 12 years.