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*:

Forms:

• Camp
• Insurance
• Travel
• Daycare/School/College:
  – Admission
  – 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.

Letters:

• 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
• Adoption
• Recommendations for private school admission
• Complicated insurance claim justifications