Fairfax Pediatric Associates, PC
Comprehensive Health Care for Infants, Children & Young Adults
(703) 391-0900

New Patient Forms
Patient Registration (pdf)
Financial Policies (pdf)
Acknowledgement of Receipt of Privacy Policies (pdf)
Privacy Policies (pdf)

Other Office Forms
Medical Record Release for 18 year olds (pdf)
Authorize to Transfer Medical Records out (pdf)
Authorize to Transfer Medical Records in (pdf)
Consent to Treat (pdf)

Autism Developmental Screening Form (pdf)

ADHD Forms
Telephone Waiver (pdf)
Vanderbilt Teacher's Assessment Form (pdf)
Vanderbilt Parent's Assessment Form (pdf)
Vanderbilt Teacher's Follow Up Form (pdf)
Vanderbilt Parent's Follow Up Form (pdf)

Health Form Policies
   Please review our current policy on completing health/school forms.

Blank forms will not be accepted. Forms will only be accepted for completion if the patient’s name and other information has been completed.

Turnaround time for form completion is usually 7-10 business days. Parents should realize that at certain times of the year we may receive hundreds of health forms in one week, and remember that each of these has to be carefully reviewed by a physician before it is released. Parents are strongly advised not to wait until the last moment.

Forms will be held here for parents to pick up. Because of Health Insurance Portability and Accountability Act (HIPAA) regulations, forms will be released to parents only. We will mail the forms to the home address on file at your request. Please provide us with a self-addressed envelope for this purpose.

Many forms require the information to be based on an examination completed within 12 months of the date the form is completed or may require specific evaluations that were not performed at the routine physical, i.e. sport vitals, asthma/allergy treatment plans. An additional office visit may be required.  No form will be completed without a physical examination in our office within the past 2 years.

Forms are completed on the basis of examinations conducted by providers in the medical group only. Examinations performed by other health facilities will not be co-signed by our providers.

The fee for having a form filled out is as follows:

NO charge - up to two forms at the time of the well child exam. $10.00 per form for any additional forms.

$10.00 fee per form for any forms brought in at any other time.

$30.00 for “Rush Service” forms that need to be completed within 24 hours.

The front office staff does not have the authority to alter, reduce, or change charges. Insurance companies do not reimburse for form completion and we do not bill insurance for completing any forms.

FORMS:

In order for forms to be filled out properly:
1. Your child's medical record must be pulled by the clerk
2. Form filled out and reviewed by a nurse
3. Form reviewed and signed by a physician or nurse practitioner

There is a $10.00 fee PER FORM. This fee will apply to school forms, camp forms, medication forms, day care center forms, sports forms, travel forms, State Department forms, etc. These fees will be waived for the first TWO forms only if you bring the forms in to be completed at the time of your child's well child visit or routine medication follow-up visit (i.e. Asthma medications, ADD medications, other chronic medications.) Note, we will not fill out forms at regular "sick" visits. If you are not sure about the difference between a "sick" visit and a "routine medication follow-up visit" please ask us to explain this to you.

THIS WILL REQUIRE THAT YOU PLAN AHEAD! ASK YOUR SCHOOL/ORGANIZATION FOR FORMS AND ANTICIPATE YOUR NEEDS PRIOR TO YOUR CHILD'S WELL CHILD VISIT OR ROUTINE MEDICATION FOLLOW-UP VISIT.


LETTERS:

Effective January 1, 2005, the following policies will apply to letters of reference or consultation:
1. Request must be in writing with a release of information authorization by the parent or legal guardian
2. Written request must include the purpose/content of the letter as well as the title, name, and address to whom the letter is intended
3. Letters to consulting physicians/hospitals will not incur a fee.
4. All other letters will incur a fee of $25.00 per letter.
5. If you would like a copy of the letter mailed to you, a self addressed stamped envelope must accompany the request.