OUR LOCATION
3515 Dallas Highway
Suite C
Marietta, GA 30064
(P)  770-943-9150
(F)  770-218-0278


Office Hours
M/T/Thu/Fri: 9-5
Wed: 9-1
Lunch: 1-2




Office Information Page

We offer a number of forms in PDF format that you can download (using the free Adobe Reader software) and print out. Filling out these forms prior to your office visit can save you time.

The BRIGHT FUTURES and DEMOGRAPHICS forms are especially important and should be completed before your visit.

DEMOGRAPHICS (FAMILY REGISTRATION FORM)

BRIGHT FUTURES FORMS
2-5 DAY BRIGHT FUTURES
1 MONTH BRIGHT FUTURES
2 MONTH BRIGHT FUTURES
6 MONTH BRIGHT FUTURES
9 MONTH BRIGHT FUTURES
12 MONTH BRIGHT FUURES
15 MONTH BRIGHT FUTURES
18 MONTH BRIGHT FUTURES

2 YEAR BRIGHT FUTURES
3 YEAR BRIGHT FUTURES
4 YEAR BRIGHT FUTURES
5 YEAR BRIGHT FUTURES
6 YEAR BRIGHT FUTURES
7 YEAR BRIGHT FUTURES
8 YEAR BRIGHT FUTURES
9 YEAR BRIGHT FUTURES
10 YEAR BRIGHT FUTURES

11-12 YEAR BRIGHT FUTURES
13-14 YEAR BRIGHT FUTURES
15-17 YEAR BRIGHT FUTURES
18-21 YEAR BRIGHT FUTURES




Patient Information/Insurance
We do not accept Peach State, Ambetter, Kaiser, Amerigroup or Humana HMO

Transfer of Medical Records
This is how we obtain your old medical records from previous physicans' offices.

Medical Records Release
Permission to Send Records
Click Here for Medical Records Request Form for Treatment Purposes

PLEASE NOTE: You do not have to have your previous doctors' medical records with you at your initial visit.



Notice of Privacy Practices
As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Notice of Privacy Practices (Rev. 7/16/11)


Other Forms

Medication Questionnaire
Medication Check Questionnaire

Receipt of Notice of Privacy Practices Written Acknowledgement Form (Rev. 7/16/11)

Financial Policy Form (Rev. 7/18/11)










 


Copyright 2011 Summit Pediatrics All Rights Reserved