Forms will only be accepted for completion if the patient’s name and other information has been completed.
Turnaround time for form completion is usually 7-10 business days.
Parents should realize that at certain times of the year we may receive hundreds of health forms in one week, and remember that each of these has to be carefully reviewed by a physician before it is released. Parents are strongly advised not to wait until the last moment.
Forms will be held here for parents to pick up.
Because of Health Insurance Portability and Accountability Act (HIPAA) regulations, forms will be released to parents only. We will mail the forms to the home address on file at your request. Please provide us with a self-addressed envelope for this purpose.
Many forms require the information to be based on an examination completed within 12 months of the date the form is completed or may require specific evaluations that were not performed at the routine physical, i.e. sport vitals, asthma/allergy treatment plans. An additional office visit may be required. No form will be completed without a physical examination in our office within the past 2 years.
Forms are completed on the basis of examinations conducted by providers in the medical group only.Examinations performed by other health facilities will not be co-signed by our providers.
The fee for having a form filled out is as follows:
NO charge - up to two forms at the time of the well child exam.
$10.00 per form for any additional forms.
$10.00 fee per form for any forms brought in at any other time
$30.00 for “Rush Service” forms that need to be completed within 24 hours.
The front office staff does not have the authority to alter, reduce, or change charges. Insurance companies do not reimburse for form completion and we do not bill insurance for completing any forms.
In order for forms to be filled out properly:
Your child's medical record must be pulled by the clerk
Form filled out and reviewed by a nurse
Form reviewed and signed by a physician or nurse practitioner
Try to plan ahead. Please ask your school/organization for forms that you may need filled out. Try to anticipate your needs prior to your child's well check visit
Request must be in writing with a release of information authorization by the parent or legal guardian Written request must include the purpose/content of the letter as well as the title, name, and address to whom the letter is intendedLetters to consulting physicians/hospitals will not incur a fee. All other letters will incur a fee of $25.00 per letter.If you would like a copy of the letter mailed to you, a self addressed stamped envelope must accompany the request.
Fairfax Pediatric Associates provides the highest quality, state-of-the-art, comprehensive health care to infants, children, and adolescents in Northern Virginia. FPA is proud to be a pro-vaccine pediatric practice.