New Patient Forms

COMING SOON

NOTICE OF PRIVACY POLICY

This policy describes the routine uses and disclosures of the patient's protected health

information.  It also includes your health policy rights. 

REGISTRATION FORM

Fill information for the children you want to register to be patients of Wishing Well Children's Clinic.

ASSIGNMENT OF BENEFITS

This agreement allows Wishing Well Children's Clinic to file a claim to your insurance for the services rendered.

RECEIPT OF NOTICE OF PRIVACY POLICY

This is to acknowledge that we have shared the Notice of Privacy Policy.

MEDICAL RECORDS RELEASE

Provide information of your child's previous doctor to enable us to obtain his/her previous medical records.

WAIVER OF NON-

COVERED SERVICES

This form is to acknowledge that your insurance may not cover some of the services performed.  Any services provided that are not covered will go to patient responsibility.

T: 832.856.4600 | wishingwellchildrens.com

Rosabelle McConkey, MD | Pediatrician | Katy, Texas

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