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Pediatric Patient Registration Forms in Tampa, FL

Pediatric Patient Registration Forms at Julia Barriga M.D. P.A. in Tampa, FL

Check in or bring in a completed registration form to expedite your visit. For more information, call at (813) 984-8846.

Thank you for choosing Julia Barriga M.D. P.A. Pediatric Clinic. Please click below to complete the “Patient Registration form”. All patients are served as they arrive.

PATIENT NON-DISCRIMINATION POLICY

 JULIA BARRIGA, MD., PA. will not discriminate in the provision of health care services to an individual:

1. Because the individual is unable to pay for the health care services;

2. Because payment for those services would be made under Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP); or

3. Based upon the individual’s race, color, sex, age, national origin, disability, religion, gender identity or sexual orientation.

Office Policy

Office Policy (English)
Office Policy (Spanish)
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

OFFICE POLICY (ENGLISH)

Review the Office Policy to understand our guidelines and procedures for your visit

OFFICE POLICY (ENGLISH)
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

OFFICE POLICY (SPANISH)

Revise la Política de la Oficina para comprender nuestras pautas y procedimientos para su visita

OFFICE POLICY (SPANISH)

Vaccine Policy

Vaccine Policy (English)
Vaccine Policy (Spanish)
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

VACCINE POLICY (ENGLISH)

Complete the Vaccine Policy form to comply with our vaccination guidelines

VACCINE POLICY (ENGLISH)
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

VACCINE POLICY (SPANISH)

Complete el formulario de Política de Vacunación para cumplir con nuestras pautas de vacunación

VACCINE POLICY (SPANISH)

13 Year and Older Privacy Policy

13 Year and Older Privacy Policy (English)
13 Year and Older Privacy Policy (Spanish)
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

13 YEAR AND OLDER PRIVACY POLICY (ENGLISH)

Review the 13-Year and Older Privacy Policy to stay informed about the protection of your personal information

13 YEAR AND OLDER PRIVACY POLICY (ENGLISH)
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

13 YEAR AND OLDER PRIVACY POLICY (SPANISH)

Revise la Política de Privacidad para mayores de 13 años para mantenerse informado sobre la protección de su información personal

13 YEAR AND OLDER PRIVACY POLICY (SPANISH)

Authorization for Treatment

Authorization for Treatment (English)
Authorization for Treatment (Spanish)
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

AUTHORIZATION FOR TREATMENT (ENGLISH)

Complete the Authorization for Treatment form to grant consent for medical care

AUTHORIZATION FOR TREATMENT (ENGLISH)
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

AUTHORIZATION FOR TREATMENT (SPANISH)

Complete el formulario de Autorización de Tratamiento para otorgar el consentimiento para la atención médica

AUTHORIZATION FOR TREATMENT (SPANISH)

Patient Portal User Agreement

Patient Portal User Agreement (English)
Patient Portal User Agreement (Spanish)
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

PATIENT PORTAL USER AGREEMENT (ENGLISH)

Acknowledge the Patient Portal User Agreement to access and manage your healthcare information securely

PATIENT PORTAL USER AGREEMENT (ENGLISH)
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

PATIENT PORTAL USER AGREEMENT (SPANISH)

Acepte el Acuerdo de usuario del Portal del paciente para acceder y administrar su información de atención médica de forma segura

PATIENT PORTAL USER AGREEMENT (SPANISH)

Patient/ Family update information

Patient/ Family update information (English)
Patient/ Family update information (Spanish)
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

PATIENT/ FAMILY UPDATE INFORMATION (ENGLISH)

Fill out the Patient/Family Update Information form to provide any changes in your personal or family details

PATIENT/ FAMILY UPDATE INFORMATION (ENGLISH)
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

PATIENT/ FAMILY UPDATE INFORMATION (SPANISH)

Complete el formulario de Actualización de información del paciente/familia para proporcionar cualquier cambio en sus datos personales o familiares

PATIENT/ FAMILY UPDATE INFORMATION (SPANISH)

Insurance Information

Insurance Information (English)
Insurance Information (Spanish)
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

INSURANCE INFORMATION (ENGLISH)

Complete the Insurance Information form to verify your insurance details for medical billing

INSURANCE INFORMATION (ENGLISH)
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

INSURANCE INFORMATION (SPANISH)

Complete el formulario de información del seguro para verificar los detalles de su seguro para la facturación médica

INSURANCE INFORMATION (SPANISH)

Newborn To 3yo New Patient Package Forms

Newborn To 3yo New Patient Package Forms (English)
Newborn To 3yo New Patient Package Forms (Spanish)
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

NEWBORN TO 3YO NEW PATIENT PACKAGE FORMS (ENGLISH)

Fill out the Newborn to 3YO New Patient Package Forms to ensure we have your child’s medical and personal information

NEWBORN TO 3YO NEW PATIENT PACKAGE FORMS (ENGLISH)
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

NEWBORN TO 3YO NEW PATIENT PACKAGE FORMS (SPANISH)

Complete los formularios del paquete para pacientes nuevos, desde recién nacidos hasta los 3 años, para garantizar que tengamos la información médica y personal de su hijo.

NEWBORN TO 3YO NEW PATIENT PACKAGE FORMS (SPANISH)

4 Years And Older New Patient Package Forms

4 Years And Older New Patient Package Forms (English)
4 Years And Older New Patient Package Forms (Spanish)
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

4 YEARS AND OLDER NEW PATIENT PACKAGE FORMS (ENGLISH)

Submit the 4 Years and Older New Patient Package Forms to establish your child’s care and health records

4 YEARS AND OLDER NEW PATIENT PACKAGE FORMS (ENGLISH)
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

4 YEARS AND OLDER NEW PATIENT PACKAGE FORMS (SPANISH)

Envíe los formularios del paquete para pacientes nuevos de 4 años o más para establecer los registros de atención y salud de su hijo

4 YEARS AND OLDER NEW PATIENT PACKAGE FORMS (SPANISH)

Sports Physical Forms

Sports Physical Forms
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

SPORTS PHYSICAL FORMS

Review and complete the Sports Physical Forms to confirm your child’s fitness for sports participation

SPORTS PHYSICAL FORMS

Sliding Fee Forms

Sliding Fee Policy
Sliding Fee Application
Sliding Fee Schedule
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

SLIDING FEE POLICY

Read the Sliding Fee Policy to learn about the flexible payment options for qualifying patients

SLIDING FEE POLICY
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

SLIDING FEE APPLICATION

Complete the Sliding Fee Application to access affordable healthcare options based on your financial status

SLIDING FEE APPLICATION
Pediatric Patient Forms at Julia Barriga M.D. P.A. in Tampa, FL

SLIDING FEE SCHEDULE

Refer to the Sliding Fee Schedule for detailed information on fee reductions based on income

SLIDING FEE SCHEDULE

 

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