Parent Forms & Office Policies
All requests will be processed in 2-3 days. Please call the office at (212) 874-4500 if you are requesting a same day appointment.
You may download and print any of our forms listed below before coming to our office. This will get you out of the waiting room and in to see the doctor a lot quicker! You may either bring them with you to the first visit, or if you wish, fax them to us before your appointment.
You may download Adobe Reader for free at www.adobe.com.
- Flu COVID Questionnaire
- New Patient Form
- 18 and Older - Patient Form
- Financial Policy Form
- Patient Registration for Flu
- Vaccine Consent Form in Absence of Parent/Guardian
- Release of Records Form
- Lactation/Edinburgh Information Sheet
- Notice of Privacy Practices
- New Patient Registration
- HIPAA Consent Form
- Annual Practice Fee (APF) Information Sheet
- Annual Practice Fee (APF)
- Vaccine Consent Form in Absence of Parent/Guardian
- Parent or Caregiver Flu/Covid Vaccination Registration Form
- Release of Medical Records
Insurance Information
We participate with most local and many national insurance plans. However, it is your responsibility to understand whether your insurance has limits on the doctors you can see, or the services you can receive.
If you provide complete and accurate information about your insurance, we will submit claims to your insurance carrier and receive payments for services. Depending on your insurance coverage, you may be responsible for co-payments, co-insurance, or other deductible amounts.
Form Policy
Our online patient portal offers a convenient way to submit your health forms. Please complete and upload your forms through the patient portal.
There is a $10 administrative fee for all camp and school forms to be completed within 7-10 business days.
A $25 administrative fee will be charged for all expedited forms. Expedited forms will be completed within 1-2 business days.
A $35 administrative fee will be charged for all same-day forms.
Completed forms may be downloaded from your child’s portal or picked up at the front desk. If you need a form mailed to you, please provide us with a self-addressed stamped envelope.
WESTSIDE PEDIATRICS ANNUAL PRACTICE FEE (APF)
We at Westside Pediatrics remain committed to providing you with the highest level of care. Through compassion, communication, and clinical excellence, we continue to build and maintain trusted partnerships with our patients and their families. The Covid 19 pandemic has altered our lives in so many ways. This includes significant challenges for small businesses. Pediatric practices have not been spared from economic strain. Westside Pediatrics is an independent practice that accepts most insurance plans. We respect that your family’s health insurance comes at significant expense. We are strongly committed to our practice model, as we feel it remains the best way for us to provide accessible, outstanding care for your children.
Based on the economic realities of current times, our strong desire to maintain our valued model, and the financial constraints of practicing in New York City, as of May 2023 we will require the payment of an annual fee.
The Annual Practice Fee (APF) will be $350 per patient, and will be due annually in the month of May. New families who join our practice throughout the year will be prorated accordingly. Please click here to pay your APF.
If you feel this fee represents an undue financial burden for your family, please contact our office administrator at APF@wppc.pcc.com.
We are honored and thankful for your continued confidence in Westside Pediatrics. This change in financial policy will enable us to continue to provide the highest quality of personalized care and accessibility. The information sheet provides further details regarding our Annual Practice Fee.
If you have further questions regarding our Annual Practice Fee, please contact us via email at APF@wppc.pcc.com.