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:

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


TOP