Santa Rosa Pediatrics
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Welcome and thank you for choosing Santa Rosa Pediatrics of Florida P.A. 
We appreciate the opportunity to provide your child with quality pediatric care.

If you have medical coverage with a managed care plan, please be sure that Luis A. Ghiglino, M.D. is the doctor you have selected as your Primary Care Physician.

 

In order to expedite the forms process, here are some common forms you may need for your visit. Feel free to print and bring the completed forms with you to the visit.

 

If you have any question of how to fill them out we will be happy to assist you.

 

1.     Patient Information Form (include financial policy).

2.     Consent by Proxy for Non Urgent Pediatric Care (This forms means you are giving authorization for the people you list to seek medical treatment for your child/children in your absence.)

3.     Authorization for Release Medical Information to Santa Rosa Pediatrics.

4.     Knowledge of receipt of notice of privacy practice

5.     Preauthorization to treat minors (16 years and older) Form

 

 

 

·        Please bring your insurance card and vaccine records with you to your appointment. 

·        If your child is a foster child or adopted, please bring a copy of guardianship records for our office to copy for our records. 

·        Please have the name, address and phone # of your prior doctor so we may get your previous records. 

·        If this visit is a Physical, please wear lightweight clothing.

     

 

We look forward to meeting you and your child/children.

 

                           

                                                           

                                                            Sincerely,

                                                            Luis A. Ghiglino, M.D., P.A.

 

 

 

 






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