Commonwealth Pediatrics Forms & 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.

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.