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 Tufts Health Together with 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.
• 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.