CAPE COD PEDIATRICS
 
CAPE COD PEDIATRICS

FORMS & NEW PATIENT INFO

NEWBORNS

TRANSFER PATIENTS

GENERAL

*Contact Insurance Company
Hospital Form

Family History Form

Registration Form

Release Form

HIPPA & Privacy Practices

*Contact Insurance Company

Release of Records Form

Family History Form
 
Registration Form

Release Form

HIPPA & Privacy Practices

Medical Release Form

Request for Medical Records to Transfer to our Practice

 

Electronic Email Consent

Referral Form- Please also see our Referral Page.


Contact form :
Contact Information

This Form is for Non Emergent questions. Please give us 48 hours to respond!

First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code: (5 digits)
State:
Daytime Phone:
Evening Phone:
Email:
Comments:

NEWBORNS

TRANSFER PATIENTS

GENERAL

*Contact Insurance Company
Hospital Form

Family History Form

Registration Form

Release Form

HIPPA & Privacy Practices

*Contact Insurance Company

Release of Records Form

Family History Form
 
Registration Form

Release Form

HIPPA & Privacy Practices

Medical Release Form

Request for Medical Records to Transfer to our Practice

 

Electronic Email Consent

Referral Form- Please also see our Referral Page.


Contact form :
Contact Information

This Form is for Non Emergent questions. Please give us 48 hours to respond!

First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code: (5 digits)
State:
Daytime Phone:
Evening Phone:
Email:
Comments:

 

 

Depending on your child's age, you will be asked to print and complete various forms for a well visit.
These forms are available at our office but it will facilitate your visit if you complete them in advance and bring them.

FORMS
Of the forms you will be completing, only the Behavior Health Screens (Peds Response, PSC and PSC-Y, and M-Chat) are billable to your insurance company. These are completed by the patient or parent and "scored" by the medical provider. Beginning at age 14 your child's doctor will also complete the Crafft behavior screen. There is no form to complete - it is verbal, but it is billable to your insurance company. Behavioral Screening is performed at the recommendation of the State of Massachusetts. If you wish to decline them you must advise us in advance. All other forms are informational only.

TESTING
At ages 6 months or 1 year and 2 years - 10, we recommend Vision Testing (VEP Testing - Diopsys) . At age 6 months or 1 year and annually thereafter we recommend Hearing Screening (Otoacoustic Emissions Testing). Please call your insurance company in advance of the visit to confirm if you will have any cost share. These are important tests but if you have a deductible we want you to have all necessary information before going forward with the testing.



NEWBORNS

ALL OTHER NEW PATIENTS

GENERAL
*Contact Insurance Company

Registering as a New Patient

Immunization Agreement

Hospital Form

Family History Form

Registration Form

Release Form

HIPAA & Privacy Practices		 *Contact Insurance Company

 Family History Form

Registration Form

Release Form

HIPAA & Privacy Practices

Personal Health History

Immunization Agreement		 Financial

General

For The Well Child

Results Call

 

 

How to Register as a New Patient

Prior to your child's first appointment, you will need to provide us with a completed registration form, insurance information, and medical records to include immunizations and last physical. There are also policies and other information we will need for you to review and sign before your first visit. For your convenience most of this information can be reviewed on line, printed, and returned to us prior to the first visit. If you prefer we are also happy to mail this paperwork to you. Once all information has been returned to our office, please allow 48 hours to register your child.



For the Well Child Visit

1 Month - 4 Months
  • Peds Response Form - To be completed in office
6 Months
9 Months
  • Peds Response Form - To be completed in office
1 Year
15 Months
  • Peds Response Form - To be completed in office
18 Months
3 Years - 6 Years


Financial
Payment Plan Agreement
If you require monthly payments to resolve an unpaid balance, please complete and return this form to our billing office.

Over 18 Payment Acknowledgement

       

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