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 Centers for Disease Control (CDC), American Academy of Pediatrics (AAP) and State of Massachusetts guidelines to keep our patients and our staff healthy during this ever changing time.

For everyone’s health and safety:

  • We are now seeing most patients in the office, but may offer a televisit or car visit when appropriate.
    • If you have a TELEVISIT scheduled, please be at your phone or computer and ready to log in at the time of your appointment.
  • Our nurses are still handling heavier than usual call volumes. We will call you back as quickly as possible. If you are waiting for a call back, please be near your phone and able to answer the call. Be mindful that some phone carriers may not show the caller ID, so it may come through as an unknown number.
  • If you or your child have or think that you may have COVID, Call our office before coming into the building.
  • Remember that although we see many mild cases of COVID in the community, it is still a highly contagious disease. Please be mindful that as a pediatric medical office, we have many patients who have compromised immune systems or are newborns and have not yet built up an immune system. COVID, flu or other contagious diseases can be life threatening to this population. Please do your part to keep our patients and community healthy and safe.
  • If you have any questions, please call our office at 978-475-4522 before coming into the office.

Forms & Requests

Registration & Insurance Form

Please complete the Registration & Insurance form to register a new patient OR to update information for a current patient.

Download Form PDF

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

Download Form

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.

Prescription Requests

We receive a high volume of requests for prescription refills. To expedite getting your refill completed, please:

  • If you are overdue for a physical or med check, we may not be able to fill the prescription. Please call the office to schedule those appointments.
  • Whenever possible, have your pharmacy request the refill. This is transmitted electronically and is typically faster.
  • If you are requested a controlled substance, or any other medication that cannot be refilled through the pharmacy – Please complete the online Prescription request
  • Please allow 48 hours / 2 business days (Monday – Friday) from receipt of the refill request for completion
  • We cannot guarantee refill requests will be processed over the weekends.
    We will contact you with any questions
  • Many pharmacies are experiencing delays in restocking some medications, especially ADHD medications. Please plan ahead as it may take a few days after sending the prescription for the pharmacy to fill the order.
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.
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!

Download Concussion Rating Scale


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.

Download Full Policy

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.

Patient Portal

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.

Download Full HIPAA Policy

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.


Download PDF

Vaccine Policy
Andover Pediatrics Vaccine Policy

Our mission is to provide the best care possible for each child in our practice. Our provider team strongly believes in the power of vaccines to save lives and does not believe there is any existing sound scientific data to support any link between vaccines and developmental or neurological disorders. As a group we are committed to recommending the AAP and CDC approved vaccine schedule.

The American Academy of Pediatrics 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. The recommended immunization schedules for children and adolescents can be found on the CDC website.

Andover Pediatrics Vaccine Schedule

CDC Vaccine Schedule

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.

Download Financial Policy

We are changing computer systems to EPIC in March! During the transition, there will be less appointments available and we’ll be responding a bit more slowly while we learn the new system and transition all of the patient information. We appreciate your patience!