Forms - Gramercy Pediatrics

There is a standard service charge of $15 for any form completion ($50 for expedited service – same/next business day if the physician is in the office). This amount is due at the time the forms are submitted to our office. Please allow 5-7 business days for processing.  The forms will be sent to you in a password protected PDF with a six digit numerical code (no slashes).  For example- if your child’s date of birth is January 15, 2003 the code will be 012003.

Delegation of Consent Form

> Download as a Word Doc
> Download as a PDF

Medical Records Release Form

If you are new to us (PDF)
If you need us to send your info elsewhere (PDF)

HIPAA/Prescription Consent Form

 Assignment of Benefits Form

 Credit Card Form