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.
Daycare, School, Camp, and Sports Forms
Our practice will gladly complete the form supplied by the school, camp, daycare or other facility for a $25.00 fee. Completion of all forms require the child to be up to date on a well visit exam. For patients 3 and older, a well visit exam must be within one year.
Please allow 5 business days for forms to be completed. Not including weekends/holidays when the office is closed.
Download and complete the Request for Completion of Form by utilizing the link below.
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.
NICHQ Vanderbilt Assessment Scales
Please talk to your/your child's provider prior to completing the Vanderbilt forms.
- 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