Forms
All of our online forms are HIPPA compliant.
Online Non-covered Services Waiver Use this form to agree to services provided in our office
Online Submission of copy of insurance card Provide us with a copy of your insurance card securely
Update your demographic or insurance information if something has changed (eg. your address, email address, insurance information)
Review our Financial Policy and Acknowledgement Online or PDF
Notice of Privacy Practices – PDF or Online Acknowledgement of Receipt of Notice of Privacy Practices
Online Waiver to speak to parents/guardians of patients 18y and older Complete this waiver to give parental permission for providers to speak/contact your parent/guardian (18yr and older)
Online Waiver for portal access for parents/guardians of patients 18y and older Complete this waiver to give parental permission for parents/guardians to have access to your patient portal (18yr and older)
Policies
Camp and Sports Forms Policy
It’s camp and sports form season!
During the spring and summer, especially, we have an abundance of requests for camp and sports forms to be completed. We receive many, many forms per day and it’s an all hands operation to get them completed in a timely fashion. We work on these in between patients, our regular duties and well into the night. There will no longer be a charge for individual camp forms as it is now included in our Comprehensive Administrative Plan. If you have been in our office for your annual physical you can find a completed copy of the CT health form in your patient portal that can be downloaded and provided to camp. If your camp requires a specific form, we can complete that as well. We ask that you upload the form and include it in a portal message to us and we will return it to you. Or if you would prefer, you can drop it off at the office.
Here’s what you can do to help:
Please allow a week to 10 days for your form to be completed. If you know your child is going to camp or needs a sports form, don’t wait to bring us the form!
Make sure your portion of the form is completed before you bring it to the office or upload it onto your patient portal; that will save time since we cannot complete our portion without it!
Please provide a list of any medications with dosages that your child will be taking at school or at camp so we can confirm that nothing has changed from our records.
Divorced or Separated Parents
You may have an agreement regarding the cost of health care for the children with the other parent. That agreement is between you and we are not a party to it.
The parent who brings in the child and is requesting service is the parent who is responsible for the bill and is considered the guarantor. This may be different from the primary insurance holder. However, there is only one guarantor and unfortunately, we can only bill one person. Any cost sharing arrangements will need to be done outside of our office between the parents.
For instance, if you are the guarantor and the other parent is responsible for 30% of the cost of health care you will need to pay the office in full and collect separately from the other parent. We cannot bill the other parent for the balance. We can accept payments from multiple people for the account, but the bill for any unpaid balance will only go to one person.
Returned checks: $20 fee
Be sure to use the correct account when writing checks. If a check is returned to us from the bank you will be charged $20 in addition to the amount of the check.