Forms
Form Completion Policies for Schools, Sports, Camps, and Medications:
We provide the following forms at no charge:
- Connecticut Blue and Yellow Forms
- Authorization for administration of acetaminophen, ibuprofen and diphenhydramine(Benedryl)
- Forms completed as part of an office visit. *Note that some especially complex forms, such as Family and Medical Leave Act paperwork, need to be completed as part of an office visit dedicated to that purpose.
- Forms completed for patients on Medicaid (Husky) insurance.
For all other forms, we charge $15 per form. This includes authorizations for administration of prescription medication ordered by us and custom forms required by schools, colleges, camps, sports organizations, and other organizations such as Boy Scouts, Girl Scouts, and High Hopes.
Forms that need to be completed the same day as requested, we charge an extra rush fee of $10 per form.
Parents need to allow 5 business days for completion of forms.
Completed forms can be picked up 7 days a week in the Essex office, or can be mailed to families.
Medication Authorization Request Form is to be filled out completely by the patient or guardian in order for Wildwood Pediatrics to begin the process. We provide medication authorization forms for acetaminophen (Tylenol), ibuprofen (Motrin, Advil) and diphenhydramine (Benadryl) free of charge. For all other medications we charge a flat free of $15 per patient. In general, the doctor or practice that prescribed the medication should be the one supplying the authorization form for it. To begin the process, please print the Medication Authorization Request Form below, fill out and bring in to one of our offices.
Authorization for the Release of Patient-Identifiable Health Information
Patient Privacy and following the law is of upmost importance for us. There are laws affecting the handling of patients’ medical information and they formalize much of what we have always done here at Wildwood to protect your right to privacy. However, they do affect some common situations, restricting our ability to take shortcuts, even with your permission, even as a courtesy to longstanding friends and patients.
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