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.
Please download any of the following forms as needed:
HIPAA/Prescription Consent Form
Assignment of Benefits Form