Practice policies
Click on the titles below to download the form:
- Adolescent confidentiality policy
Please review our office policy about privacy and confidentiality with your child aged 13 and over.
- Adolescent transition information
Please review this packet if you are a patient aged 18-22 thinking of transitioning to an adult health care provider.
- Divorced and/or separated parents policy
Please review our office’s policy about communication between and with divorced and/or separated parents.
- Emergency room and urgent care policy
Please review our office policy regarding emergency room and urgent care visits.
- Financial policy
Please review our office’s financial policy prior to your first visit at Commonwealth Pediatrics; you will be asked to sign stating you’ve reviewed it.
- Immunization policy
Please review our office’s policy around immunizations/vaccines.
- Instructions on changing your Medicaid insurance plan
Please review these instructions on how to enroll your child with Wellsense Boston Children’s ACO.
- Office no-show and late arrival policy
Please review our office’s no-show and late arrival policy.
- Psychiatric medication refill policy
If your child takes medication for ADHD, ADD, anxiety, or depression, please review our office policy regarding medication refills.
- Referrals and authorization policy
If your child sees a specialist, please review our referrals and authorization policy.
Practice forms
Click on the titles below to download the form:
- Authorization to speak with parent or guardian for patients 18 and over
Please review and sign this form if you are a patient aged 18 and older.
- Authorization to release medical records
Please review and sign this form if you need to transfer medical records to or from Commonwealth Pediatrics.
- Authorized representative form
Please review and sign this form if you need someone other than a parent or legal guardian to bring your child to an office visit.
- Consent to treatment and assignment of benefits
Please review and sign this form allowing us to bill your insurance for visits at Commonwealth Pediatrics.
- Insurance waiver
Please review and sign this form if your insurance is inactive on the day of your appointment.
- New patient registration form
Please complete and sign this form if you are registering as a new patient with Commonwealth Pediatrics.
- Notice of privacy practices/HIPAA
Please review our office’s privacy practices prior to your first visit at Commonwealth Pediatrics; you will be asked to sign stating you’ve reviewed it.