Patient Forms

Insurance Referral Forms

Insurance referral forms for specialist may be requested by calling during normal office hours. Please have available the name and address of the specialist, along with the diagnosis/problem related to the visit. A referral form may also be requested by downloading a request form using the following link and faxing the completed form to (301) 681-4268.

• Insurance Request For Referral

Daycare, School, Camp, and Sports Forms

A signed standard health form can be generated that contains the age-appropriate health information and has been approved by the state of Maryland for child care facilities and is accepted by local Maryland school systems.

Please allow 5 business days for forms to be completed. In order to ensure compliance with Health Insurance Portability and Accountability Act (HIPAA), forms can only be mailed to the home address, picked up during normal business hours at our office, or sent electronically as an attachment to a portal message (electronic copy only).

There is a $15.00 charge for the standard form and a $25.00 charge if a facility's form must be completed or if a parent prefers their forms to be filled out by the doctor.

Download and complete the Request for Completion of Form by utilizing the link below.

• Request for Completion of Forms

Standard Health Form Samples

• Standard Form – Child Care-Preschool- K-1
• Standard Form – Grades 1-5 – Middle School-High School- Camp

Request for Medical Records

Summaries or copies of medical records are available with written request. Utilize the link below to download a Medical Records Request Form. The completed form may be mailed, delivered, or faxed to (301) 681-4268.

• Request for Medical Records

NICHQ Vanderbilt Assessment Scales

• NICHQ Vanderbilt Assessment Scale — Teacher Informant
• NICHQ Vanderbilt Assessment Scale — Parent Informant

Additional Patient Forms

• Notice of Privacy Practices - Describes how health information about you (as a patient of this care center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.
• Authorization for Release of Medical Information - Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.
• Authorization and Consent for Treatment - All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorizacion y Consentimiento Para el Tratamiento.
• Preferred Contacts - Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos.
• Financial Policy - This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.
• Language Services