INFORMATION & FORMS
Various required forms are available on this page. Our office staff and/or providers may direct you to this page to print out and complete forms prior to your visit.
All the forms are in PDF format and require Adobe's Acrobat Reader which is free. If you do not have Acrobat Reader you can download it here.
Monday - Thursday: 7:00am-7:00pm
Please call the office at 410-569-3300 to make an appointment with one of our providers!
If you are experiencing a medical emergency, please call 911 or go to your nearest emergency room.
INSURANCE AND BILLING
We participate with most insurance companies and welcome self-pay patients. We do not
participate with any Medicaid/medical assistance plans. Please be aware that payment is due at
the time of service for self-pay individuals. Should you have any questions
regarding insurance or billing matters, please call the office Monday through Friday, 410-569-3300.
HAS YOUR INSURANCE CHANGED?
If you are currently a patient at our practice and your insurance has changed please bring your new
card with you to your next visit.
All co-pays are due at the time of the visit unless prior arrangements have been discussed with the billing staff. Fees for office visits are expected at the time of service if you have deductibles, co-insurance payments or services not covered by your insurance. Please refer to our financial policy for additional information.
There is a $50 fee for missed appointments per patient without 24 hour notification.
NEW PATIENT FORMS
We aim to provide care in a comfortable and fun environment! We have provided forms below to make your first visit stress-free, concise, and enjoyable. If you are unable to complete the forms prior to your first appointment, we have them available at the front desk as well.
Please plan to arrive 15 minutes early for your first appointment in order to process the paperwork. Please be sure to bring your insurance card.
If your child has been under the care of another pediatrician, we ask that you have the medical records transferred to our office including:
Most recent Well Check visit, growth charts, immunization records, lead testing results.
Any additional Well Check/Sick visit notes, specialist notes, and lab results that may be pertinent to your child's health are also encouraged.
New Patient Packet - This PDF contains a compilation of all the forms you need for your new patient visit. Please print the entire document and complete each form using the checklist on the first page. You may also download the individual documents below.
Notice of Privacy Practices
ADHD TEACHER AND PARENT RATING SCALE
SCHOOL, CAMP, DAYCARE & SPORTS FORMS
There is a $10 fee per set for completion of all health forms. Please be sure any parent’s pages are completed before giving forms to the office. Please allow 3-5 business days for completion. We will call you once the forms are ready for pick up!
HARFORD COUNTY PUBLIC SCHOOLS
Pre-participation Physical Evaluation for Interscholastic Activities
Medication Policy Permission Form
Medication Self-Carry Permission Form
Discretionary Medication Permission Form
Immunization Certificate Form (896 Form)