Drs. Black and Benton Pediatrics
  • New Patients
    • General Info
    • Philosophy
    • Coparenting & FAQ
    • New Patient Forms
    • COVID-19
  • Established Patients
    • Calling After Hours
    • Insurance Glossary
    • Yearly Physicals
    • Forms and Letters
  • Contact Us / Directions

Established Patients

Calling After Hours
Insurance Glossary
Physicals
     Annual Preventive Care
     Sports

Forms
     Special Forms and Letters
     Downloads

 

Forms

​Special Forms and Letters
Writing letters and completing forms are an inherent part of what we do as pediatricians.  Depending on the exact letter or form requested, you may incur a small charge.

No Charge
Shot records
School medication forms 
Sports forms presented during the yearly physical appointment
Letters between Drs. Black and Benton and referred specialists

Variable Charges
FMLA paperwork
​Sports forms not in conjunction with a yearly physical
Special reports, forms, or letters
 
​Downloads
Download the annually updated Patient Registration and Consent form below.  Note that patients over 18 years of age require a different form.  They also must fill out a new HIPAA form.
Patient Registration and Consent
18+ patient registration and consent
HIPAA Privacy Practices
18+ HIPAA privacy practices
Transfer Records to Drs. B&B
Financial Agreement
Missed Appointment Agreement
Knox County Sports Physical Form

Links

Healthy Children.org
Centers for Disease Control
East TN Children's Hospital
American Academy of Pediatrics

Need a sports physical?

If your child has had a physical within 365 days of your inquiry, the doctors will, in most cases, sign off on a sports physical.  Fill out the Personal and Family History Portions of this form from Knox County and drop it by the office. We'll let you know when it's ready.  In some cases you may be charged for completion of the form.

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  • New Patients
    • General Info
    • Philosophy
    • Coparenting & FAQ
    • New Patient Forms
    • COVID-19
  • Established Patients
    • Calling After Hours
    • Insurance Glossary
    • Yearly Physicals
    • Forms and Letters
  • Contact Us / Directions