Forms & Policies

Forms and Policies

For your convenience, we have provided links to many useful office and school forms in PDF format. If you need a free copy of Adobe Reader, please visit www.adobe.com.

Office Forms

Please fill out these four forms and bring them to your first visit.

Additional forms:

School Forms

Policies

School Forms

Health forms are required by many organizations including schools, daycare, camps, and school athletic departments. Health forms that are brought to a well child examination will be completed at that office visit. When forms are required at other times, they will be completed within 7-10 business days. There is a $10 charge for each form.

Prescription Refills

Please call your pharmacy and have them fax a refill request to our office at 703-522-0495. This allows your physician to verify that your current prescription is appropriate and refilled properly.

Please call to request ADHD medication refills.

Overnight Telephone Calls

For urgent medical issues and questions between 10 pm and 8 am, the answering service will initially connect you to a pediatric telephone nursing service. Please note that this after-hours nursing service is not covered by most insurance plans. There will be a charge of $25 to cover the telephone nursing service.

Missed Well Child Appointments

Please notify us if you cannot make a well child appointment at least 24 hours in advance.  Without advanced notice, there will be a $50 fee for missed well child appointments.

Sports Physical Appointments

Virginia High School League (VHSL) guidelines require completion of a sports pre-participation physical between May 1st of the current calendar year through June 30th of the upcoming year.  If your child has had a well-child exam prior to May 1st of this year, he/she will need to come into the office for a sports physical with updated medical history and physical examination prior to completion of the sports clearance form.  Unfortunately, most insurers do not cover the cost of this additional visit, required by VHSL as of March 2013.  We charge a self-pay flat rate of $75.00; this will include VHSL physical form, which is collected at the time of your appointment.

Letter of Medical Necessity

We ask parent or legal guardian to submit a written example of the letter requested describing the medical necessity including the title, name and address to whom the letter is intended. Once the letter has been reviewed it is up to the provider’s discretion to generate and sign the letter.  There will be a charge of $25. Letters to consulting physician/hospital will not incur the fee.

Notice of Privacy Practices