Policies / Forms
To ensure that parents have a clear understanding of our healthcare operations and of their financial responsibilities, we have created the following policies. Please read these thoroughly before your child’s appointment. We are happy to answer any questions you may have.
- Office Policies
- Financial Policy
- Payment Policy
- FAQ on Insurance Terms (copay, coinsurance, deductible,etc...)
New Patient Forms
For your convenience, we have provided these PDF forms for you to complete at home and print off to bring to your appointment.
Note: In order to view or print these forms you will need Adobe Acrobat Reader installed. Click here to download it.
- Patient Registration Form
- Patient Registration 1 (For children with the same birth mother and birth father OR who are all adopted)
- Patient Registration 2 (Please use this individual registration form for children with a different birth mother or father)
- Financial Policy Form
- Office Policies & Vaccine Policy Forms
- Newborn Coverage (for newborns)
Please also bring the following items to your child’s first appointment:
- Your child’s insurance card (the actual card or a printed paper copy of both sides)
- Parent’s driver’s license or State ID
- Your child’s immunization record (printed paper copy)
- Medications your child takes regularly (if medication must be kept refrigerated, then a list of medications and dosages is acceptable).
Record Release Forms
Transfer IN to Palatine Pediatrics NEW patients transferring into Palatine Pediatrics should complete this form to have records obtained from their previous doctor. We require a copy of all new patients vaccine records, growth charts and last well visit notes.
Transfer OUT of Palatine Pediatrics Patients wishing to transfer out of Palatine Pediatrics must complete this form to obtain a copy of their child's records. If the patient is over the age of 18 years old or is no longer a legal minor, the patient must complete this form. Please allow 2 weeks for records to be prepared.