Medical Forms & Letters Request Policies
There will be no charge for forms completed when a patient is seen for an office visit or regular checkup, for forms that a family has prepared that only require the physician’s signature, or for prescriptions that are for previously prescribed medications (refill prescriptions). Forms for siblings not examined will incur a $10.00 charge per form. Payment is required in advance of preparation of the requested form or letter
Listed below are examples of the types of forms and letters that are subject to a $10.00 charge*:
– Sports participation
– Immunization (form 3231)
– Hearing/vision (form 3300)
– Hardship transfers
- State Forms:
– TEFRA/Katie Beckett* Due to the complicated nature of these forms, this will incur a $35.00 charge per child.
- Requests such as special diets, extra school books for home use, etc.
- Special needs placement
- Appeals/medical necessity letters for insurance companies
- Travel-related issues
- Recommendations for private school admission
- Complicated insurance claim justifications
These links will allow you access to printable office forms. Note these forms should not be emailed back to the office. If you prefer, you can fax these to us at 770-772-6099, or bring them with you on your next visit."
- Patient Information Sheet - Attention New Patients - This form is now done in the office on one of our iPads. Please come in 20 minutes before your scheduled appointment so we can get your child in our system and keep them on time for their first appointment with us.
- Consultation Form
- Medical Record Release
- Vanderbilt ADHD ADD Parent Form
- Vanderbilt ADHD ADD Teacher Form
Use these links to find more information about topics listed:
- American Academy of Pediatrics
- American Diabetes
- Centers for Disease
- Children's Healthcare of
- Children and Adults with Attention Deficit and Attention Deficit Hyperactivity
- The Cord Blood
- Immunization Schedules from the
- US Dept of Health and Human Services
- Vaccine information from the CDC