As many of you know, we recently switched our electronic medical record (EMR) system and need to update our database with the most current patient information. For existing patients only please fill out the registration form and return to us at least two days prior to your scheduled appointment or plan to come to your appointment 15 minutes earlier than scheduled. You can also fill out the form securely online. This form needs to be filled out for ALL patients. You may list all children on the same form.
In order for your pediatrician to communicate with specialists outside of our practice the following form needs to be completed.
- Authorization for Release of Information via Care Everywhere [pdf] [secured online form]
- Please review our Financial Policy [pdf] [secured online form]
- Waiver to Enroll in MyChart [pdf] [secured online form]
- Pre-Natal Registration [pdf] [secured online form]
- Specialist Release of Information Form [pdf] [secured online form]
We value the privacy and confidentiality of our adolescents and young adults. We have a consent form in the office for them to complete.
Similarly, if your child was seen at an Emergency room and we do not have access to the records of the visit, we may need you to fill out this form.
Please fill out this form if you require a copy of your child's medical record for any reason (e.g., moving, transferring care to another doctor, or for your own personal use).
- Medical Record Release [pdf] then email, fax or mail in form.
The HIPAA document below describes how medical information about you may be used and disclosed and how you can get access to this information.
Please review it carefully.
If you have any questions about this notice, please contact our Practice Manager at (617) 969-8989.
7/2018 HIPPA- read-only
In order to view or print these forms, you will need Adobe Acrobat Reader installed.
Click here to download it.
We as a practice believe that all children should be vaccinated according to the CDC and AAP guidelines for vaccination schedule. You may review it here: CDC vaccine schedule