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 permission to take part in physical school activities, please complete the form in ink or fill it out online then print it and bring to your well-care appointment.
Forms may take 2 business days to process. There is a $10 charge for urgent forms which are not provided to MDPA at the time of the patient’s visit. If a letter is needed, there will be a $30 fee. We’ll call you when it’s complete or message you in your My Kid’s Chart portal. Please note: Your child will need to have a well visit within the past year before we can complete this form.
New Patient Fillable Paperwork
Complete most of your new patient paperwork before your first visit, log into your patient portal at mdpa.pcc.com/portal, or at the purple icon on the 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.
If you need to release records for an adult child, please have the patient fill out the Adult Authorization. The patient should fax the signed form to us for placement in the permanent record.
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. 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.
