Are You New Here?
Welcome to MDPA, your Patient-Centered Medical Home. We look forward to serving your family!
New PatientsPhysicals
If your child needs a physician’s evaluation to take part in band or athletic school activities, please complete the form in ink or fill it out online then print it and bring to your well-care appointment.
There is a $5 fee to process if not presented in conjunction with a well visit and may take 1-3 business days. There is a $25 charge for a rush fee for (due immediately or within 24 hours; must be submitted by 3:00 pm for same-day return. If received after 3:00 pm, the form will be ready by 1:00 pm the following business day) urgent forms which are not provided to us at the time of the patient’s visit, to cover the cost of preparation. We’ll call you when it’s complete or message you in your portal.
Please note: Your child will need to have a well visit within the past year before we can complete this form. A sports physical (briefer than well care) can be substituted if well care was within the past calendar year, but the school requires a visit in the last 6 months.
You can find the most up to date Texas UIL physical eval form at uiltexas.org/athletics/forms. Under Medical forms select: Athletic and Marching Band Pre-participation Physical Evaluation.
New Patient Fillable Paperwork
Complete much of your new patient paperwork before your first visit inside your new patient portal, My Kid’s Chart. Log into your patient portal at mdpa.pcc.com/portal, or at the purple icon on the mdpedi.com home page, and go to Create Message. Drop to the subject New Patient Forms, complete the answers and sign all those signature forms then attach a copy of the front and back of your insurance card and the front of your driver’s license and hit SEND. Be aware that the system times out after 15 minutes, so if you’d like to do the message several times and start where you left off, that will work too!
Thanks for joining us at MD Pediatric Associates. See you soon!
Permission to Treat
If you’d like to authorize another adult to consent for treatment of your child in your absence, please fill out the Permission to Treat form. Fax the completed form to us at (469) 671-5437 or drop a copy into your patient portal at My Kid’s Chart.
If you need to release records for an adult child, please have the patient fill out the Adult Authorization. The patient should upload the signed form through the patient portal for placement in the permanent record. This will also suffice when you need to get back into the portal of an 18 year old adult patient.
Medical Release
To have your former physician’s office release your child’s records, please complete this form and fax it to your former physician
You’ll also need to complete this form if you want to authorize our office for a medical records release regarding those kept at MD Pediatric Associates. Upload completed forms through your patient portal or fax completed forms to us at (469) 671-5437.
If a former patient is over 18, we will need a signed Adult Authorization form to release records to mom or dad.
To request a shot record or a copy of a previously filled physical form, please log into your Patient Portal. If you have not received an invitation to be a proxy for your child on our Follow My Health patient portal, please email [email protected] with your child’s name and DOB and we will send you an invitation.
ImmTrac2
ImmTrac2 is the Texas Department of State Health Services Immunization Registry provided at no cost to all Texans. The registry is secure and confidential, and safely consolidates and stores immunization records from multiple sources in one centralized system. ImmTrac2 requires signed parental permission for a patient’s shots to be stored until the patient reaches 18 years old.
