18 & Over – HIPAA Release and Consent Form
Why am I getting a copay on a physical?
Credit and Collection Policy:
We pride ourselves on providing exceptional, state-of-the-art medical care and extended services for our patients. Sometimes insurance companies choose not to pay for recognized service codes. In most cases, any non-covered service is your responsibility. Please take the time to understand the insurance plan you have and refer to our website for the schedule of well visits to see the services provided at each visit.
*Effective 3/31/2023
Cancellation and No-Show Policy:
All no-shows and cancellations of physical exams within 24 hours of the appointment will be charged $50.00.
*Effective 6/19/2015
18 and up:
Once our patients turn 18, by law, we are required to have a signed permission to speak form on file. This form must be completed and signed by the patient themselves. Parents, we understand that it may be frustrating when you call the office and are told that we need the signed form before a provider or nurse can speak with them, but this is the law and we must follow it.
*updated 5/18/2023
Record Release Policy:
The charge for copying records is $15 per child, payable up-front at the time of the request. We will make every effort to make the copies available as soon as possible but please know that, by law, we have up to 30 days.
*effective 2/17/2023
Do you need a prescription refill?
Effective immediately, prescription refills will require 3 days’ notice. However, most refills will be handled by the next business day. Prescriptions for ADD/ADHD medication or any other controlled substance will only be refilled Monday thru Friday. Thank you in advance for your understanding.
*effective August 2, 2021
Do you need Camp, Sport, or Blue school forms?
Forms will be available for pick up on the third business day after drop off. There is a $10.00 fee per form, payable at the time of pick up. As always, we will provide a CT State Blue Form at the time of your child’s physical FREE OF CHARGE, there is a $10 fee if additional copies are needed. Thank you for your anticipated cooperation in this matter.
*effective 4/02/2019