Northside Cherokee Pediatrics| Dr. Jamie Rollins Northside Cherokee Pediatrics| Dr. Jamie Rollins
Jamie Rollins MD,  alt=

Patient Information

New Patient Registration Forms

Please click on the links below, print out and complete the BOTH the Registration forms AND the New Patient Medical History/Immunization Forms below. Additionally, please bring the following items to your first appointment:

  • Insurance card
  • Photo ID
  • Physician referral form (if applicable)

New Patient Registration Forms (Registration + Financial Policy + Medical Practice Annual Acknowledgement)

New Patient Medical History/Immunization Forms


Existing Patients Forms

If any of the following applies to you, we request that you please download and complete the Registration Forms below and bring them with you to your next appointment:

  • Your appointment will be your first one this calendar year
  • You have had a change in address or phone number since your last visit
  • You have had a change in your medical insurance since your last visit

Patient Registration Forms (Registration + Financial Policy + Medical Practice Annual Acknowledgement)


Medical Records Release

If you would like a copy of your medical records, please complete the form below or fax it to us at Holly Springs Office: Fax (678) 388-5489 or Towne Lake Office Fax (770) 852-7721.

Please allow two weeks for this request to be completed.

Medical Records Release


Associated Brochure Downloads for your Reference

Patient Rights & Responsibilities

HIPAA Notice of Privacy Practices

Partnership for Safety Information Guide


Insurance

We accept most major health insurance plans, however it is your responsibility to contact your insurance carrier to verify coverage and benefits. Patients may be held financially responsible for payment of services should the insurance company deny responsibility. Be sure to bring your insurance card with you every time you visit Northside Cherokee Pediatrics. Notify the front desk whenever your insurance coverage changes so that the medical staff can accurately maintain your important medical records.


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Office Locations

Holly Springs Office
684 Sixes Road, Suite 220
Holly Springs, GA 30115
Phone (678) 388-5485
Fax (678) 388-5489

Directions

 

Towne Lake Office
900 Towne Lake Pkwy., Suite 306
Woodstock, GA 30189
Phone (770) 852-7720
Fax (770) 852-7721

Directions