Forms & Policies

Practice Forms

• Medical Release Form
• Consent to Treat a Minor Child
• Consent for Patient Policies

Practice Policies

• Notice of Privacy Practices
• Practice Immunization Policy
• Practice Immunization Policy (Spanish)
• Adolescent Privacy Policy
• Adolescent Privacy Policy (Spanish)
• Billing Update
• Billing Update (Spanish)
• Financial Policy
• How Do I Transition to Adult Medicine?
• MA Laws Medical Treatment of Minor and Emergency Treatment of Minor

Laboratory Testing & Your Insurance

Lab tests, x-rays, & other testing ordered by your physician may or may not be covered.  Coverage may vary based on individual insurance plans or diagnosis.  Deductibles and/or co-insurance may apply to your testing (even when ordered by your primary care physician or specialist).  All tests requested by third party sources (school, daycare, work, court, other insurers, military, etc.) will not be covered by your insurer.  You will be responsible for payment.  Coverage will vary. Please check your subscriber certificate or consult with your insurance carrier directly to inquire about coverage details. 8/2012

Relationship to Patients

In an effort to ensure an accurate family history in our patients’ accounts, we will be asking those accompanying our patients to the office to identify themselves clearly as mom/dad, stepmom/dad, or whichever relationship applies.  When bringing a child or adolescent into our office, our check-in staff and medical assistants will be asking your relationship to the patient. This will apply when calling our office as well.  We want to be sure to secure our patients privacy rights and not release any information to anyone but a parent or guardian. Thank you for your understanding and please do not hesitate to call us with any questions. 4/2010

Traveling & Long-Distance Calls

Please be aware that if you are traveling out of the country we are happy to assist you during normal business hours.  Although we are limited in the services we can provide, especially when you are out of the country, we are available for questions.  Also, be aware that for any calls that need to be returned out of area, you will be held financially responsible. 5/2008

Late Policy

We make an effort to be on time for every appointment. Unfortunately, when even one patient arrives late, it can effect the remainder of the day’s appointments. Please note that patients arriving more than 15 minutes after their scheduled appointment time will be asked to reschedule.

No Show Policy

We understand life can be hectic and managing schedules is challenging. However, we do expect that you will make every effort to attend all scheduled appointments. When a patient doesn’t show up for a scheduled appointment, it is a missed opportunity for another patient who could have used that appointment slot.

Any missed appointment without sufficient notification is considered a “no show”. We kindly ask that you provide, at minimum, 3 hours advanced notice for cancelled or rescheduled appointments. No showed appointments will be charged a $25 fee. Repeated no showed appointments will be subject to dismissal from our practice.