Andover Pediatrics Forms & Policies
We know that the COVID pandemic has meant a lot of changes in routines and in healthcare, and seems to be becoming the new normal. We continue to follow American Academy of Pediatrics (AAP) and State of Massachusetts guidelines to keep our patients and our staff healthy during this ever changing time.
Forms & Requests
Registration & Insurance Form
Please complete the Registration & Insurance form to register a new patient OR to update information for a current patient.
Records Request form
To request a copy of your / your child’s medical records:
- Complete the Medical Records Request form
- Submit payment for the $10 processing fee
- Patients age 18 yrs and older MUST sign the form themselves, parents cannot request records for a patient age 18+
- Requests sent without payment will not be processed
Request a MYCHART Account
School & Camp Form Requests
We receive a high volume of requests for school and camp forms. To expedite getting your form completed, please:
- Please complete the online School & Camp Form request
- Be sure that you have completed any family history or personal info on the form
- Attach your form and submit to our office
- Please allow 5 business days from receipt of the form for completion
For most school and camp forms – the child must have a current physical (a physical within the last 365 days) for completion. If your child is overdue for their physical, you may need to schedule and complete the physical before the forms can be completed and sent.
If we cannot read the document or have any questions, we will contact you.
Refill Requests
We receive a high volume of requests for prescription refills. To expedite getting your refill completed, please request on your MyCharty account.
Referral Requests
Please fill out the form below or contact us with the information.
- If your plan requires referrals for visits to specialists, it is your responsibility to obtain the referral from our office staff in advance of the visit.
- Do not assume that we have submitted a referral if your doctor recommends that you see a specialist.
- We can only process a referral once you have made an appointment and have provided us with the following information.
- It is your responsibility to confirm if that specialist is in-network for your insurance. We are not responsible for billing by the specialist. Feel free to call our office for names of alternate specialists if needed.
Sickle Cell Request Form
Concussion Rating Scale
If you are coming in for a concussion follow up visit, please complete this form the day of your visit, with how you are feeling TODAY, then bring this with you to the visit. Thank you!
Policies
Late & No-Show Policy
At Andover Pediatrics we strive to provide every patient with timely and efficient care. In order to maintain a smooth schedule and respect everyone’s time, we ask that you adhere to the following policies regarding appointments, lateness, and cancellations. Please allow enough time to take the elevator up to our suite on the 2nd floor, the elevator can be slow.
Arriving for Your Appointment
- Please arrive 15 minutes prior to your scheduled appointment time to allow time to fill out forms and complete check-in.
- Always bring your insurance card and co-payment to every visit.
Late Arrivals
- Patients who arrive more than 10 minutes late to their scheduled appointment will be asked to reschedule.
- Late arrivals disrupt the schedule and impact other patients’ care. We appreciate your effort to arrive on time.
Cancellations and No Shows
- If you need to cancel or reschedule an appointment, please give at least 24 hours’ notice.
- Repeated late arrivals, no-shows or late cancellations may result in dismissal from the practice.
We understand that unexpected situations arise, and we aim to be as accommodating as possible. By keeping appointments and arriving on time, you help us provide the best possible care to every patient.
Adolescent Confidentiality Policy
As patients become adolescents, they take more responsibility for themselves and for their own health care. We want both patients and their parents to understand this increased independent role of the adolescent, and that our primary concern responsibility is for them and for their needs.
Our policy is consistent with Massachusetts law, the American Academy of Pediatrics and Society for Adolescent Medicine.
Patient Portal Policy
Our Patient Portal has been completely updated! You can now view your school forms and immunizations, pay bills online, send questions to our team and more! You can find a Guide to navigating the Patient Portal here.
HIPAA Notice of Privacy Practices
Your Information. Your Rights. Our Responsibilities.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Parents who are Separated or Divorced
Policy Regarding Children Whose Parents are Separated or Divorced
Many of our patients are children whose parents are either separated or divorced. Our primary concern for these children is to promote their health and well-being. In such situations, we are happy to work with either or both parents to make sure the child’s healthcare needs are met.
When a minor child visits our office accompanied by either parent, we will assume that parent has full or joint legal custody, hence the authority to make medical decisions for the child, unless we are instructed otherwise, in writing, by a legal authority.
It is essential that we can depend on the child’s parents to communicate clearly with each other about the child’s health status and healthcare plans. Our general approach is to communicate our medical assessments and recommendations with the parent who accompanies the child to the office, or with the parent who contacts us by telephone or electronic communication.
It is not feasible for us to take the responsibility of contacting each parent separately every time we see the child in the office. We are, however, happy to receive inquiries about the child’s health from either parent at any time.
We cannot mediate financial disputes between the two parents. When children visit our office, we hold the accompanying parent or guardian responsible for any payments required, regardless of the divorce decree. Any disputes about reimbursement for medical expenses need to be settled between the parents privately. The guarantor will be listed as the parent who holds the insurance policy, that parent will receive the bills. If you have specific payment arrangements in place as part of the Divorce or Custody agreement, please share that document with us.
Our priority is the health and well-being of your child, and we are happy to support each family in that goal.
Vaccine Policy
Andover Pediatrics Vaccine Policy
Our mission is to provide the best care possible for each child in our practice. As a group, we are committed to recommending the American Academy of Pediatrics (AAP) approved vaccine schedule. Our practice uses evidence-based care and follows the guidelines and recommendations by the AAP.
- We firmly believe in the effectiveness of vaccines to prevent serious illness and to save lives.
- We firmly believe in the safety of our vaccines.
- We firmly believe, based on all available literature, evidence, and current studies, that vaccines do not cause autism or other developmental disabilities.
- Vaccine preventable diseases can and do return in unvaccinated populations.
The AAP strongly recommends immunizations as the safest and most cost-effective way of preventing disease, disability and death. The AAP calls for the on-time routine immunization of all children and adolescents according to its policy.
Learn More AAP Vaccine Information
Effective 7/10/2025 our practice will not accept new families that do not vaccinate their children in accordance with our policy. Established patients that are behind on the State of Massachusetts required vaccines will be given sufficient notice and time to bring their children up to date. The vast majority of our patients are current on their vaccines. Patients that are behind on the required vaccines will be given one month to begin to comply with our vaccine policy. If your child is behind, we will provide easy access to getting your child up to date. Families that decline to follow the vaccine schedule may be discharged from the practice.
Fees & Payment Policy
Thank you for choosing Andover Pediatrics. Please review the attached Patient Financial Policy for full details on billing and patient responsibilities. We hope that this information helps you to better understand how your healthcare visits are billed, and how your insurance plan deductibles and copays work.
Health care billing and insurance plan coverage has become increasingly complicated and regulated. Please feel free to ask any questions, and to reach out to the customer service number on your insurance card to learn more about what you will be financially responsible for.