Forms

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.

Please download any of the following forms as needed:

Registration Form and Insurance Information

HIPAA/Prescription CONSENT FORM

Assignment of Benefits Form

Office Policy on Insurances and Payments

Lab Fee

Late/Missed/Cancelled Appointment Policy



Delegation of Consent

 

HIPAA/Prescription Consent Form

 Assignment of Benefits Form

 Credit Card Form


*** IMPORTANT NOTICE ***

Due to the Coronavirus pandemic, we are converting the majority of our visits to telehealth. Please download the Healow App. IN ORDER TO KNOW HOW TO CHOSE US ON YOUR APP, please download the Healow Quick Start Guide.

This will enable us to provide our families with care, while limiting visits to the office and following social distancing guidelines.

As of April 15th, 2020 we are no longer participating with Oxford and United Healthcare
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