the following forms in their entirety and send them to our office. In addition, please send a copy of your child’s insurance card front and back. We will then be able to make a chart for Dr. Harum to review prior to your visit, verify insurance information and obtain any prior authorization that may be needed. Patient Registration Form Office Policies Patient Bill of Rights HIPAA Form Developmental Questionnaire Authorization for Disclosure If you do not have copies of medical records please complete the Disclosure of Protected Health Information forms, mail them to any health care provider that your child has seen who may have relevant records. They will in turn mail those records to Clinic For Special Children. Please arrive 15 minutes prior to your scheduled appointment time for registration purposes. Checklist to be mailed to Clinic for Special Children: New Patient Registration Form Developmental Questionnaire Policies Statement HIPPA Form Copy of Insurance Card (front and back) Checklist of items to be mailed to other physicians: Authorization for Disclosure Dr. Harum and the staff at Clinic for Special Children are honored you have chosen us for your child’s unique health care needs! |
| 6317 Oleander Drive Suite A Wilmington, NC 28403 Email: CSC@clinicforspecialchildren.net Phone: (910) 251-5150 Fax: (910) 251-5159 Pager (910) 254-8005 |
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| Clinic for Special Children A comprehensive resource for children with developmental disorders |