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

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 fee for "Rush Service" forms that will be completed the same day.

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.