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.

Forms for siblings not examined at the time of request will incur a $15.00 charge per form, except for TEFRA/Katie Beckett forms and letters which will incur a $50.00 charge*. 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 $15.00 charge:

Forms:

• Camp
• Insurance
• Travel
• Daycare/School/College:
  – Admission
  – Sports participation
  – Immunization (form 3231)
  – Hearing/vision (form 3300)
  – Hardship transfers

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

*TEFRA/Katie Beckett forms and Letter of Medical Necessity:  $50.00 charge.