Forms

Forms

To save time at the office, you can print and fill out the following forms prior to your next appointment.

Parent/Guardian’s Consent for Treatment

Adult Patient Consent for Treatment

In Locos Parentis Consent to Treat

Medical Practice Opt-Out Form

Patient Information Sheet

Medical History Form

Sports Physical Form – We can provide the clearance form for you in the office, but please fill out the first history portion/page prior to your appointment.

Policies

Billing and Insurance – Co-pays are due at the time of service. Some insurance will require a deductible or co-insurance for well visits and labs that may be billed directly to you after the visit. See Parent Consent form above for further details on financial policy. Please understand that your insurance policy is a contract between you and your insurance company, and we are not a party to that contract. Therefore, financial responsibility for your child’s treatment is ultimately that of the parent/guardian. You are responsible for all co-pays and deductibles prior to services being rendered. If your child does not have health insurance coverage, payment is due at the time of service unless you have made payment arrangements with our business office. We gladly accept cash, check, Visa/MasterCard/Discover/AmericanExpress credit or debit cards for payment.

No-Shows – Any time you are unable to keep your appointment, we would appreciate a call in advance from you so that we may cancel your appointment and use that time for another patient. We will contact you after a no­-show to attempt to reschedule. After the third time an appointment is missed, you may be asked to find another physician as we cannot accommodate multiple missed appointments and still provide quality care for our patients. Thank you for your compliance with this request.

ADHD Prescriptions – In order to ensure the best care for our patients and to help meet insurance guidelines for quality care, all patients currently on a controlled substance for the management of ADD/ADHD will be required to come to the office every three months for a recheck with their physician. Please remember to schedule these appointments in advance to ensure that your child can be seen for a recheck before running out of medication. Patients starting on a new medication may be required to come more frequently during the early stages of treatment in order to optimize therapy. In the instance where you are unable to keep your recheck appointment for any reason, the decision of whether or not to refill medication will be determined by your physician on a case­-by-­case basis.

Vaccine Policy – Click here to view our Vaccine Policy.

Affiliations