Please correct the errors described below.

It is our goal to accommodate as many requests as possible, bearing in mind the following:

1. Blank forms will not be accepted. Forms will only be accepted for completion if the patient information has been completed, and signed by the parent.

2. Turnaround time for form completion is usually fewer than 5 business days. While every effort will be made to complete forms as quickly as possible, parents should realize that at certain times of the year we may receive dozens of health forms in one week, and remember that each of these has to be carefully reviewed by a physician before it is released.

3. Forms will be held here for parents to pick up. Due to HIPAA regulations, forms will be released to parents only. Federal law prohibits doctors’ offices from faxing or mailing medical information to non-medical facilities.

4. Many forms require the information to be based on an examination completed within 12 months of the date the form is completed. Additionally, no form will be completed for any patient who has not had a comprehensive well child checkup in our office in more than 12 months.

5. Forms are completed on the basis of examinations conducted by physicians in this medical group. Examinations performed by “checkup centers” will not be co-signed by your physician, nor will she complete any forms based in whole or in part on any information provided by such centers. Forms are completed based on information obtained by staff from your child’s chart. All forms are reviewed by a physician for completeness and accuracy. In some cases, forms mandate that only the physician may complete them.

Please sign below that you understand our policies.

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