The following downloadable forms are available in PDF format for your convenience. We encourage you to print them off, complete them at your leisure in the privacy of your home, and bring them with you to your appointment. Please be assured that no information is being transmitted over the Internet; you are merely printing a blank form.
- Family Registration Form
- Sports Pre-Participation Examination
- Developmental Screening Forms:
- Use or Disclosure Permission Form
- Release of Records Form
- Authorization to Treat Form
- HIPAA Notice of Privacy Practices
- HIPAA Acknowledgement and Consent Form
The federal Health Information Privacy and Portability Act is designed to protect your private health information. The law requires that we ask you to sign the Acknowledgement and Consent Form once every three years. This form explains the Privacy Practices adhered to in our practice; once signed, it is kept with your child's medical records.
For your convenience, we have posted the Notice of Privacy Practices on our website. Please read it, then download the HIPAA Acknowledgement and Consent Form and bring with you to your next appointment; this saves time and inconvenience at the time of your appointment.
For appointments, call our receptionists between 8:00 a.m. – 5:00 p.m. Monday – Friday. Evening appointments are available Monday – Friday 5:00 p.m. – 9:00 p.m. and weekends from 8:00 a.m. – noon for urgent care only.
A $25 fee will be charged for any check-up not cancelled 24 hours prior to the appointment. A 24 hour notice will give us the opportunity to schedule another child who is in need of a check-up.
Pediatric Associates of Western CT accepts most insurances and will be happy to file most forms of insurance for our patients. We currently participate with the following insurance companies:
- Aetna
- Anthem Blue Cross Blue Shield
- Cigna
- Connecticare
- HealthNet
- HMC
- Magnacare
- Oxford
- PHCS/Multiplan
- Tricare (Standard)
- United Healthcare
Payment is required at the time of service. A service charge will be incurred if payment is not made at the time of service.
