Forms and Policies

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Adolescent Confidentiality Policy

Please review our office policy about privacy and confidentiality with your child aged 13 and over.

Adolescent Transition Information

Please review this packet if you are a patient aged 18-22 thinking of transitioning to an adult health care provider.

Authorization to Speak with Parent or Guardian for Patients 18 and Over

Please review and sign this form if you are a patient aged 18 and older.

Authorization to Release Medical Records

Please review and sign this form if you need to transfer medical records to or from Commonwealth Pediatrics.

Authorized Representative Form

Please review and sign this form if you need someone other than a parent or legal guardian to bring your child to an office visit.

Consent to Treatment and Assignment of Benefits

Please review and sign this form allowing us to bill your insurance for visits at Commonwealth Pediatrics.

Divorced and/or Separated Parents Policy

Please review our office’s policy about communication between and with divorced and/or separated parents.

Emergency Room and Urgent Care Policy

Please review our office policy regarding emergency room and urgent care visits.

Financial Policy

Please review our office’s financial policy prior to your first visit at Commonwealth Pediatrics; you will be asked to sign stating you’ve reviewed it.

Immunization Policy

Please review our office’s policy around immunizations/vaccines.

Notice of Privacy Practices/HIPAA

Please review our office’s privacy practices prior to your first visit at Commonwealth Pediatrics; you will be asked to sign stating you’ve reviewed it.

Office No-Show and Late Arrival Policy

Please review our office’s no-show and late arrival policy.

Psychiatric Medication Refill Policy

If your child takes medication for ADHD, ADD, anxiety, or depression, please review our office policy regarding medication refills.

Referrals and Authorization Policy

If your child sees a specialist, please review our referrals and authorization policy.