Information & forms
registration_form.pdf
Contact Information
Phone: 909-796-2400
Fax: 909-796-2443
E-mail: benejpeds@gmail.com
Website:www.benejpeds.com
Patient Portal
Unfortunately, we can no longer reply to your concerns on benejpeds@gmail.com. All future correspondence will have to go through our patient online portal on our website at http:www.benejpeds.com. Once your done with the basic registration on our patient portal, it is easy to use, It is safe and secure. It also gives you access to your records.
Open Payment Data Base
“For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.”
“The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.”
Please click on the links below to download your packets. Fill in and bring in the paperwork on the day of your appointment.
New Patient Registration Form (English) New Patient Registration Form (Spanish)
ASQ Forms: English ASQ Forms: Spanish
ASQ-3-4-M ASQ-3-4-M-S
ASQ-3-6-M ASQ-3-6-M-S
ASQ-3-8-M ASQ-3-8-M-S
ASQ-3-9-M ASQ-3-9-M-S
ASQ-3-10-M ASQ-3-10-M-S
ASQ-3-12-M ASQ-3-12-M-S
ASQ-3-14-M ASQ-3-14-M-S
ASQ-3-16-M ASQ-3-16-M-S
ASQ-3-18-M ASQ-3-18-M-S
ASQ-3-20-M ASQ-3-20-M-S
ASQ-3-22-M ASQ-3-22-M-S
ASQ-3-24-M ASQ-3-24-M-S
ASQ-3-27-M ASQ-3-27-M-S
ASQ-3-30-M ASQ-3-30-M-S
ASQ-3-33-M ASQ-3-33-M-S
ASQ-3-36-M ASQ-3-36-M-S
M-CHAT-r forms (18months to 2years)
M-CHAT-r (English) M-CHAT-r (Spanish)
Advanced Directives (18years and up)
PHQ-9 questionnaire forms (12years and up)
PHQ-9 questionnaire English PHQ-9 questionnaire Spanish
Edinburgh Postnatal Depression Screening Forms (0-12months)
Edinburgh Postnatal Depression Screening English
Edinburgh Postnatal Depression Screening Spanish
Pearls Tool English (1year and up)
Child Parent Caregiver Report Part1 De Identified Part2 Identified-English
Teen Parent Caregiver Report Part1 De Identified Part2 Identified-English
Teen Self Report Part1 De Identified Part2 Identified-English
Adverse Childhood Experiences Revised Questionnaire Adult-English
Pearls Tool Spanish (1año y más)
Child Parent Caregiver Report Part1 De Identified Part2 Identified-Spanish
Teen Parent Caregiver Report Part1 De Identified Part2 Identified-Spanish
Teen Self Report Part1 De Identified Part2 Identified-Spanish
Adverse Childhood Experiences Revised Questionnaire Adulto-Spanish
Staying Healthy Assessment
ENGLISH SHA 0 to 6 Months SPANISH SHA 0 to 6 Months
ENGLISH SHA 7 to 12 Months SPANISH SHA 7 to 12 Months
ENGLISH SHA 1 to 2 Years SPANISH SHA 1 to 2 Years
ENGLISH SHA 3 to 4 Years SPANISH SHA 3 to 4 Years
ENGLISH SHA 5 to 8 Years SPANISH SHA 5 to 8 Years
ENGLISH SHA 9 to 11 Years SPANISH SHA 9 to 11 Years
ENGLISH SHA 12 to 17 Years SPANISH SHA 12 to 17 Years
ENGLISH SHA Adult SPANISH SHA Adult
Contact Information
Phone: 909-796-2400
Fax: 909-796-2443
E-mail: benejpeds@gmail.com
Website:www.benejpeds.com
Patient Portal
Unfortunately, we can no longer reply to your concerns on benejpeds@gmail.com. All future correspondence will have to go through our patient online portal on our website at http:www.benejpeds.com. Once your done with the basic registration on our patient portal, it is easy to use, It is safe and secure. It also gives you access to your records.
Open Payment Data Base
“For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.”
“The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.”
Please click on the links below to download your packets. Fill in and bring in the paperwork on the day of your appointment.
New Patient Registration Form (English) New Patient Registration Form (Spanish)
ASQ Forms: English ASQ Forms: Spanish
ASQ-3-4-M ASQ-3-4-M-S
ASQ-3-6-M ASQ-3-6-M-S
ASQ-3-8-M ASQ-3-8-M-S
ASQ-3-9-M ASQ-3-9-M-S
ASQ-3-10-M ASQ-3-10-M-S
ASQ-3-12-M ASQ-3-12-M-S
ASQ-3-14-M ASQ-3-14-M-S
ASQ-3-16-M ASQ-3-16-M-S
ASQ-3-18-M ASQ-3-18-M-S
ASQ-3-20-M ASQ-3-20-M-S
ASQ-3-22-M ASQ-3-22-M-S
ASQ-3-24-M ASQ-3-24-M-S
ASQ-3-27-M ASQ-3-27-M-S
ASQ-3-30-M ASQ-3-30-M-S
ASQ-3-33-M ASQ-3-33-M-S
ASQ-3-36-M ASQ-3-36-M-S
M-CHAT-r forms (18months to 2years)
M-CHAT-r (English) M-CHAT-r (Spanish)
Advanced Directives (18years and up)
PHQ-9 questionnaire forms (12years and up)
PHQ-9 questionnaire English PHQ-9 questionnaire Spanish
Edinburgh Postnatal Depression Screening Forms (0-12months)
Edinburgh Postnatal Depression Screening English
Edinburgh Postnatal Depression Screening Spanish
Pearls Tool English (1year and up)
Child Parent Caregiver Report Part1 De Identified Part2 Identified-English
Teen Parent Caregiver Report Part1 De Identified Part2 Identified-English
Teen Self Report Part1 De Identified Part2 Identified-English
Adverse Childhood Experiences Revised Questionnaire Adult-English
Pearls Tool Spanish (1año y más)
Child Parent Caregiver Report Part1 De Identified Part2 Identified-Spanish
Teen Parent Caregiver Report Part1 De Identified Part2 Identified-Spanish
Teen Self Report Part1 De Identified Part2 Identified-Spanish
Adverse Childhood Experiences Revised Questionnaire Adulto-Spanish
Staying Healthy Assessment
ENGLISH SHA 0 to 6 Months SPANISH SHA 0 to 6 Months
ENGLISH SHA 7 to 12 Months SPANISH SHA 7 to 12 Months
ENGLISH SHA 1 to 2 Years SPANISH SHA 1 to 2 Years
ENGLISH SHA 3 to 4 Years SPANISH SHA 3 to 4 Years
ENGLISH SHA 5 to 8 Years SPANISH SHA 5 to 8 Years
ENGLISH SHA 9 to 11 Years SPANISH SHA 9 to 11 Years
ENGLISH SHA 12 to 17 Years SPANISH SHA 12 to 17 Years
ENGLISH SHA Adult SPANISH SHA Adult