THINGS TO REMEMBER WHEN SUBMITTING A FORM FOR COMPLETION
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THINGS TO REMEMBER WHEN SUBMITTING A FORM FOR COMPLETION
(Effective June 1, 2004)

We are happy to complete medical forms for your child or forms related to your child’s medical care.  In most cases, medical forms will require the physician or nurse to review the chart and extract clinical information for submission.  Some forms may require photocopying medical information from the chart and/or providing a separate letter or statement from the physician.  School and/or camp forms for patients with diabetes may require special insulin adjustment regimens as well.  All of these things take time away from the normal patient care day and often must be completed after office hours.  Please help us to expedite your requests by doing the following:

1. Remember to provide us with the form(s) in a timely manner.  Please understand that we will not be able to complete the form on the day that it is submitted.  Often the chart must be reviewed before the form can be accurately completed by the doctor.  One to two weeks should be allowed for form completion. 
   
2. We must have an up-to-date, signed Release of Medical Information Form in the chart.  The release of information form must be specific for each form (or set of forms) completed and must be annually resubmitted for recurring forms (such as for school or FMLA).  Remember that currently there is a $15 fee for form completion.  This is not a per page charge.  In the case of school forms, most revisions during the school year will not require an additional fee.  An exception to this may be if the child changes school districts and a new set of forms is required.  The following types of forms will be subjected to the form completion fee:
   

3. The following must be done before submitting a form to the doctor for completion:

• Fill in the portions of the form relating to your child's personal and/or demographic information such as your child's name, date of birth, home address, telephone number, school name, etc.
• Enclose a self-addressed stamped envelope if the form is to be returned by mail to a location other than your home address (e.g. the MVA).  If this information is not provided, the completed forms will be mailed to your home address.
• If you would like us to fax the form from this office, please include on the release form the name of the person or organization to receive the form, the fax number, and a telephone number (in case of faxing difficulties).  If this information is not provided, the completed forms will be mailed to your home address.
• Enclose the required form completion fee.  Make sure you indicate your child's name and “form fee” in the memo section.
• Faxed copies of medical forms may not be legible and/or suitable for submission.  If this is the case, we may ask you to resubmit these forms to us by mail or self-delivery.

Downloadable Forms


You must have Adobe Acrobat Reader to view and print these forms. If you do not have it, click here.

24 Hour Urine Collection (PDF)

Dr. Armour Pump BG Fax Sheet (PDF)

Dr. McLaughlin Lantus BG FaxSheet (PDF)

Injection BG Form (PDF)

Autorization For Releae of Medical Information

Policy Form