Consent to treat a minor Parents can give permission for their children to come in without an adult. Acceptable ages. (15,16 & 17 years of age) However, we cannot administer vaccines without a parent or guardian present in the office. Fidelis Doctor Assignment For ALL FIDELIS patients (New and Established)!!!!! Patients/parents must sign a PCP change form. Fidelis auto-assigns Dr's at random to patients when they sign up, and everytime their insurance renews, so we must have a signed PCP form on file to recieve payment. Patient Registration & HIPAA Agreement Completed forms can be faxed or mailed to the office. Fax: (518) 374-3512 Mail to: Park Place Pediatrics c/o Danielle Degener 701 Union Street Schenectady, NY 12305 Patient Proxy This form is for Parents to give permission to babysitters, daycare, grandparents or anyone that is NOT a legal guardian to bring their children (under 18 yrs old) in for their appointments. Patient Record Release (To or From our office) If Patient is 18 years or older, form MUST be completed by the patient. Motor Vehicle Accident Assignment of Benefits FOR ESTABLISHED PATIENTS ONLY In the case of a Motor Vehicle Accident, an AOB must be completed in the office or online. Financial Policy HIPAA (The Health Insurance Portability and Accountability Act) For all Patients, Dr. Hadi Koohsari is the elected Privacy Office for Park Place Pediatrics. If you have any questions regarding your right to privacy, please call the office during regular business hours.