New Patient Registration

New Patient? Fill out the form below for New Patient Registration.

Administration of Vaccines

Here at Metropolitan Pediatrics we strictly follow the vaccine schedule recommended by the Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP). We do not allow alternative vaccine schedules.

Download Immunization Schedule

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1General & Insurance Information

2Financial Policy

3Privacy Policy

4History Questionnaire

5History Questionnaire

6History Questionnaire

7 EHX Consent Forms

Patient's Name*

First Last

Date of Birth*

Sex*

Male

Female

Responsible Party*

First Last

Primary Address*

Street Address Address Line 2 City State ZIP Code

Email*

The email is used for notification purposes only. Your email will not be sold.

Primary Parent / Guardian Name

First Last

Primary Parent / Guardian Phone

Secondary Parent / Guardian Name

First Last

Secondary Parents / Guardian Phone

Best Phone Number to Receive Text Message*

Best Phone Number to Call*

Insurance Information

Insurance Plan*

Policy Holder*

Person who registered for the Insurance Plan

Policy Holder DOB*

Employer*

Work Phone*

Group / Policy Number*

Id Number*

Preferred Pharmacy

Please provide information for your preferred pharmacy where prescription needs to be sent.

Pharmacy Name*

Address*

Street Address City State ZIP Code

Pharmacy Phone*

Financial Policy

Unless proof of policy is presented prior to treatment, payment in full is due at the time of service. We accept cash, checks, VISA, MasterCard, and Discover Card. We reserve the right to discontinue service if balances are not paid.
Your appointment time is reserved for your child. There is a $25.00 charge for appointments broken without a 24 hours notice.
There is a $25 returned check charge per returned check.
In the event of default payment of charges, you agree to pay all reasonable attorney fees and collection costs.

For our insured patients

Your estimated deductible and copay are due in full at time of service. After your insurance has determined and paid its health benefits, any difference between estimated and actual amount due will be billed to you. Payment is due within 30 days.
As a courtesy we attempt to verify basic plan information and estimated co-pays. Verification is not a guarantee of payment by the insurance company or a release of the patient’s legal obligation for any part of our total bill.
If you have a managed care plan, it is your responsibility to assign Dr. Gandhi as your child’s primary care physician as of the first date of treatment. If you have a newborn, be sure to contact your employee benefits office and/or insurer within 30 days of birth to add your child to your plan. Failure to do either could result in your visit not being covered.
As a courtesy, we will file your claim to your primary insurance company. It is your responsibility to notify us of any changes to your insurance coverage prior to treatment. You are responsible for paying for services and filing your own claims if insurance payment denials are due to incorrect information you have provided.

I acknowledge full financial responsibility for services rendered by the practice, including co-payments and any charges not paid by my insurance.
I understand that payment of charges incurred is due at the time of service unless other definite financial agreements have been made prior to treatment.
I authorize payment of insurance benefits directly to Metropolitan Pediatrics (Hiren Gandhi, M.D)
I consent to treatment necessary for the care of the below named patient.
I authorize the release of all medical records to the referring physician and specialists and to my insurance company, if applicable. I allow fax transmittal of my medical records, if necessary

Financial Policy Acknowledgement*

I have read and fully understand the above consent for treatment, financial responsibility, release of medical information, and insurance authorization. As head of household or responsible party, your signature indicates acceptance of the aforementioned policies and authorizations for all family members who are current or future patients.

I have read and agree to Metropolitan Pediatrics Financial Policy

Patient Name*

First Last

Financial Policy: Parent / Guardian Signature*

Financial Policy: Parent / Guardian Name*

First Last

Financial Policy: Relationship to Patient*

Email Communication of Health Information

FACT SHEET AND CONSENT FORM

As a patient of Metropolitan Pediatrics, you may request that we communicate with you via unencrypted electronic mail (email). This Fact Sheet will inform you of the risks of communicating with your healthcare provider via email. Your health is important to us, and we will make every effort to reasonably comply with your request to receive communications via email. However, we reserve the right to deny any request for email communications when it is determined that granting such a request would not be in your best interest.

PLEASE READ THIS INFORMATION CAREFULLY

Metropolitan Pediatrics staff will make every effort to promptly respond to your requests for information via email. However, if you are experiencing an emergency, you should never rely on email communications and should seek immediate medical attention.

Risks of using email to send protected health information include, but are not limited to:

Risk of Unauthorized Access by a Third Party: Do you share a computer with your family? Is your email address or access to email provided through your employer? Do you access your email over an unsecured connection such as public Wi-Fi? Do you access your email on your mobile device? Emails may be accessed by someone you do not wish to know about your health information. Despite necessary precautions, email may be sent to the wrong address by either party. Email may be intercepted or altered in transmission by a computer hacker or computer virus.

Unique Difficulty in Verifying the Sender: Email may be easier to forge than handwritten or signed papers. Metropolitan Pediatrics will only send emails to the email address you provide, but it may be difficult to confirm that you are in fact the person sending the request for information from your email address.

Procedures

Emails are not checked outside of normal business hours – this includes overnight, on weekends or holidays.
If at any time you change your email address or wish to discontinue email communications altogether, you must notify Metropolitan Pediatrics immediately in writing.

Parent / Guardian (Primary) Email*

Parent / Guardian (Secondary) Email*

Email Communication of Health Information Acknowledgement

Consent*

I consent

By signing below, you acknowledge your recognition and understanding of the inherent risks of communicating your child’s health information via unencrypted email and hereby consent to receive such communications despite those risks. Messages containing clinically relevant information may be incorporated into the medical record at the provider’s discretion.

Consent*

I consent

By signing below, you also acknowledge that you have the choice to receive communications via other more secure means such as by telephone or in-person. By signing below, you agree to hold Metropolitan Pediatrics harmless for unauthorized use, disclosure, or access of your child’s protected health information sent to the email address you provide.

Email Communication: Parent / Guardian Signature*

Email Communication: Consent Date*

Email Communication: Parent / Guardian Name*

First Last

Email Communication: Relationship to Patient*

EHX Consent Forms

Top 10 Reasons to Opt-In

If your child ever had to be rushed to the Emergency Room at Children’s National Health System, doctors there could quickly pull up your child’s secure health record and make fast informed decisions when your child may need it most.
Your child’s doctor will be able to better track and securely share your child’s medical history.
- Children’s IQ Network is HIPAA compliant and all of your child’s health information is encrypted and protected and can be accessed only by health care providers who are caring for your child and have a need to know.
Your child’s doctor will be less likely to perform unnecessary or repeat tests and treatments that other doctors in the network have already done; as they will be able to access your child’s medications, vaccines, lab and imaging test results.
Your child’s doctor could avoid making diagnostic and treatment mistakes by using the information found on the network to make the best decisions about your child’s care.
If your child is ever seen at Children’s National Health System, their health record will be readily available to doctors at the hospital without the need for phone calls, faxes, or paper copies.
Use of the Children’s IQ Network helps to facilitate faster and better coordinated patient care between your child’s doctor, Children’s National Health System (including the ER), and any other doctors that your child sees who are part of the network.
Use of the Children’s IQ Network increases efficiency by eliminating unnecessary paperwork and handling.
Your child’s doctor could use the information found on the Children’s IQ Network to provide more effective care and treatment to your child.
Use of the Children’s IQ Network could improve healthcare quality and outcomes for all children in the network.
Use of the Children’s IQ Network may reduce the costs of care for everyone.

Would you like to Opt-In for Electronic Health Exchange?

I would like to Opt-In

I would like to Opt-Out

Single Consent to Share Medical Information with Children's IQ Network Providers Treating Me or My Child

INTRODUCTION

As part of our commitment to improve the quality and the coordination of medical care for the children and patients we serve, METROPOLITAN PEDIATRICS has elected to participate in the Children’s National Health System’s IQ Network. This innovative program is the first in the country to attempt to provide real-time coordination of care via an electronic medical record that allows an interface between your or your child’s health care provider and one of the country’s leading children’s hospitals.

This SINGLE CONSENT will allow us to share information, for example, with an ER doctor treating you or your child, or with a specialist to whom you have agreed we are to refer you or your child, so that they are able to quickly access critical information about you or your child from your medical record before beginning treatment. This should dramatically reduce the chance of medical errors, including adverse drug interactions or allergic reactions.

Your and your child’s healthcare information is encrypted (encoded) and can be accessed only by health care providers who are caring for you or your child and have a need to know.

As METROPOLITAN PEDIATRICS is a part of the Children’s IQ Network, this written SINGLE CONSENT will allow the sharing of information with any provider within the IQ Network whom you have elected to be involved in your or your child’s treatment. You do have the option to opt out of the Children’s IQ Network. If you choose to opt out, you will need to sign a separate consent form each and every time you or your child need to be seen by another member of the Children’s IQ Network other than those at METROPOLITAN PEDIATRICS.

PATIENT RIGHTS: I have received a copy of the Children’s IQ Network (CIQN) Information Sheet. I understand that patient information will still be stored electronically for my provider’s records, and that an electronic health summary will be available to other providers through the CIQN. I also understand that I have the right to not share (opt-out) health information with other providers within the CIQN.

PROTECTED DISCLOSURE OF INFORMATION: I understand that Children’s National complies with all federal and local regulations including the Health Insurance Portability and Accountability Act; and that this Consent includes my agreement that Children’s National can use private health information for my treatment or my child’s treatment as defined in the Notice of Privacy Practices. I agree to Children’s National use of de-identified health information about me or my child for appropriately reviewed and approved research and quality improvement activities.

I consent to share medical information with Children's IQ Network Providers Treating Me or My Child*

I consent

Request to Not Share My Information within the Children's IQ Network

I hereby request to not have my healthcare information shared with other health care providers within the Children’s IQ Network®. I understand that all of my healthcare information collected by my health care provider will not be submitted to the Children’s IQ Network®, and will not be seen by or shared with other health care providers within the Children’s IQ Network®. I understand that my healthcare information will continue to be available to my primary health care provider as this information makes up my personal medical record.

I further understand that I will be permitted to change my decision and allow sharing with other health care providers within the Children’s IQ Network® at any time in the future.

I would like to opt-out of Electronic Health Exchange

I agree

Consent for Administration of Vaccines

Here at Metropolitan Pediatrics the vaccine schedule recommended by the Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) is followed. Alternate schedules put children at risk for serious illness and as such, cannot be followed. The staff at Metropolitan Pediatrics do not wish to put patients and the public at risk by allowing refusal or intentional delay of vaccination. We are passionate about the need for vaccinating children, including your children and our own. Trust is a very important part of the physician-patient-parent relationship. Unfortunately, not trusting a pediatrician or nurse practitioner about the effectiveness and safety of vaccination may lead to lack of trust regarding other aspects of pediatric care. We do not wish to put you or us in that position. If vaccination goes against your beliefs, please make arrangements to find another provider who can accommodate your requests.

Otherwise, please sign below stating that you are aware of our vaccination policies and that we strictly adhere to CDC/AAP guidelines.

I have read and agree to the Consent for Administration of Vaccines*

I agree to Metropolitan Pediatrics Administration of Vaccines policy.

No Show Policy

Patients with 3 no-shows in a year or a family with 4 no-shows in a year will be terminated from the practice. If you’re unable to keep a scheduled appointment please give us at least 24 hours advance notice to ensure that you will not be charged a $25 no-show fee for the appointment. Thank you for your understanding, cooperation, and consideration for others.

I have read and agree to the No Show Policy*

I agree to Metropolitan Pediatrics No Show Policy

No Show Policy: Parent / Guardian Signature

No Show Policy: Parent / Guardian Name

First Last

No Show Policy: Relationship to Patient