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12 Month Old Milestones 15 Month Old Milestones 18 Month Old Milestones 2 Month Old Milestones 24 Month Old Milestons 36 Month Old Milestones 4 Month Old Milestones 48 Month Old Mileston 6 Month Old Milestone 60 Month Old Milestones 9 Month Old Milestones Abnormal Involuntary Movement Scale (AIMS) Adult ADHD Form Adult Anxiety scale Adult depression questionnaire Bed wetting Child ADD/ADHD Demo Adult Demo Child Depression screening (Child) Headache Intake KHSAA COVID-19 Return to play Narrative description of child (parent) New Patient Information New Patient Information Pediatric health assessment form - 11 to 14 years Pediatric health assessment form - 2 to 3 years Pediatric health assessment form - 4 to 5 years Pediatric health assessment form - 6 to 10 years Pediatric health assessment form-15 to 18 years Pediatric health assessment 15-18 months Pediatric health assessment 19-23 months Pediatric health assessment 2-4 months Pediatric health assessment 5-7 months Pediatric health assessment 8-14 months Pediatric Symptom Checklist Youth 12-17 Pediatric Symptom Checklist Youth 6-11 PHQ- 9: Modified for Teens Record Release (from us) Request of Prior Records Screen for Child Anxiety Related Disorders (SCARED) (to be filled out by parent/guardian) Suicide Risk Screen ASQ tool

Request of Prior Records

Manish Dixit, M.D., F.A.A.P.1902 S. US HWY 59, Suite 5Parsons, KS. 67357(620)421-0002 phone(888)820-2325 fax

Please fill out only the lines with the * next to them.

Patients Name *

Patients DOB *

Patient Address *

Hereby authorize: Doctor/Clinic (Prior Dr.) *

Prior Dr (s) Phone # *

Prior Dr (s) Fax # *

To disclose protected health information to:

Dr. Manish Dixit, M.D. 1902 US Hwy 59, Suite5 Parsons, KS 67357

For the following purposes: *

clinical care

Information to be disclosed *

Medical records

This authorization expires: *

1 year to date

I understand that requested information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment of alcohol and drug abuse. This information will be released unless objection is made by checking the statement below:

Do not release my health records pertaining to:

Sexually transmitted disease

AIDS

HIV

Mental Health Services

Alcohol and/or drug abuse

If the person or entity receiving this information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be disclosed to other individuals or institutions and no longer protected by these regulations. You may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain treatment or payment or your eligibility for benefits. You may inspect or copy the protected health information to be used or disclosed under this authorization. For protected health information created as part of a clinical trial, your right to access is suspended until the clinical trial is completed. Finally, you may revoke this authorization in writing at any time by sending written notification to M. Dixit LLC. Your notice will not apply to actions taken by the requesting person/entity prior to the date they receive your written request to revoke authorization.

Electronic Signature of patient or representative: *

Today's Date *

patient / representative filling out form : *

Relationship to Patient : *

Verification of Information Released

* Required field