New patients:
Records Transfer Form (Complete and give to us or your former provider’s office)
General Consent Form  (Sign and give to us)
Initial History Questionnaire  (Complete and give to us)
Immunization and Physical Exam Schedule

Sports Physical Forms

History Form for ALL schools
Vermont Sport Form

New York Sport Form

What to Expect at Visits

Save time in appointments by printing and completing the highlighted forms associated with each visit before you arrive!

MMR policy
Measles can be a severe, debilitating, and even deadly illness for children.  It is also highly contagious.  At Middlebury Pediatric and Adolescent Medicine, we care for many patients, who, because of prematurity, immune system problems, or the inability to be vaccinated due to young age, are at high risk for severe consequences of measles infection.  These patients often have frequent visits at MPAM, potentially increasing their risk of exposure.

In order to protect all of our patients, including the most vulnerable, the physicians at Middlebury Pediatric and Adolescent Medicine have determined that we must require vaccination against the measles virus.  To remain in this practice, children must receive the MMR vaccine unless it is medically contraindicated.  We are unable to make any exceptions for religious or philosophical exemptions.

The MMR vaccine is extremely effective and well-tolerated, and we are confident in the safety of this vaccine for your child.   However, we understand if you have concerns or questions regarding this new requirement, and we welcome you to call or schedule an appointment if you would like to discuss it further.
We thank you for your understanding and willingness to help protect both your child, and the most vulnerable members of our practice from this dangerous illness.

Late policy
If you arrive more than 15 minutes past your scheduled appointment time we may need to reschedule your appointment.

No show policy
We understand that life happens and you may not always be able to make it to your appointment. Please let us know as soon as possible if you cannot make it. If we do not hear from you, we will consider it a no show appointment. After the second no show, we will send you a letter. After the third no show, our care coordinator will contact you to see if she can help you make future appointments. If there is a fourth no show, we will be forced to dismiss you from the practice.

Refills
Please contact your pharmacy to request medication refills, including any controlled substances. This also applies if you have no refills left on your bottle(s). Your pharmacy will  contact us with your medication needs. Refill requests take 48 to 72 hours (or 3 business days) to process. Requests made on a Friday will be processed the next business day.

Unfortunately, we cannot process refill requests over the weekend.


Prescriptions

How can I refill my medication?
Please contact your pharmacy to request medication refills. This also applies if you have no refills left on your bottle(s). Your pharmacy will contact us with your medication needs. Refill requests take 48 to 72 hours (or 3 business days) to process. Requests made on a Friday will be processed the next business day.

Can I use a Mail Order Pharmacy?
For our office to send scripts to your mail order pharmacy we will need you to contact the insurance company that you have the pharmacy benefits with. (The phone number should be on the back of your card.) Please let us know which Mail Order Pharmacy you will be using with your medications.

What if my prescription is a Controlled Substance or Narcotic?
These medications require a written script to be hand carried to your pharmacy. Please call 388-6347 and ask for a refill line. Refill requests take 48 to 72 hours (or 3 business days) to process. Requests made on a Friday will be processed the next business day.


Appointments

Will someone remind me of my visit?
As a service to our patients, we have implemented a telephone appointment reminder system, HouseCalls, to provide you with the courtesy of a timely reminder of your next scheduled appointment.

HouseCalls will call you 2 days prior to give you the day, date and time of your appointment. You will also be able to either confirm or cancel the appointment by using your telephone keypad.

Press the 1 Key to confirm the appointment
Press the 2 Key to repeat the message
Press the 3 Key to cancel the appointment

If you are unavailable when the call is made and have voicemail or an answering machine, the system will leave you a brief message.

What if I can’t make it to my appointment?
If you should need to cancel and/or reschedule your appointment, please call us at 802-388-6347. We require 24 hours notice for all cancellations. If you do not call us in advance of your appointment time, you will be considered a “No Show”. After 3 “No Shows” you may be dismissed from our practice.

What should I bring to my appointment?
Please bring your insurance card and photo ID with you to your appointment. When you check in, notify us of any changes in your insurance coverage.

Test Results

When can I expect my test results?
Our policy is to notify patients of all test results, either by phone or by mail. Unless there is an unanticipated abnormal result or one that requires urgent attention, it may be up to 10 days for you to get your results, longer for some tests. Be assured that all tests are reviewed for urgency by a clinical staff member as soon as we receive them, even if the ordering provider is not immediately available. Please do not call for results unless you have not heard from us by 2 weeks after the test was performed.

Can I view my test results on-line?
Yes! Test results are available on the patient portal. Be assured that all tests are reviewed for urgency by a clinical staff member as soon as we receive them, even if the ordering provider is not immediately available. Please do not call for results unless you have not heard from us by 2 weeks after the test was performed. Please be sure to register for the Patient Portal in person before attempting to log in.


Referrals to other Providers

What should I do if I’m referred to another provider?
If your provider has determined that you must be seen by an outside specialist, i.e., cardiologist, podiatrist, etc., we can make that appointment for you and call with the information. We will send appropriate medical records required for your care to the specialist. You may also require an insurance referral. Depending upon your insurance, pre-certification/prior authorization may need to be completed in order for your insurance company to pay for those visit(s).
Workers Compensation

What if my visit is covered by Workers Compensation?
Please provide the date of injury, employer, and worker’s comp liability insurance. Failure to provide this information at the time of your visit will result in the bill being sent to you as a “self pay”. You will then be responsible for submitting the bill for payment.
Medical Records & Patient Confidentiality

Does the Electronic Medical Record compromise my privacy?
It is our responsibility to protect the confidentiality of your medical records at all times. Records may only be released with the written consent of the patient or the patient’s legal guardian. If at any time you feel your privacy has been violated, please contact Customer Service at 802-388-5699.

Can I transfer my records?
If you would like your records transferred, you must sign a release statement giving us permission to share your records or send information to another office. It usually takes 30 days to transfer/copy your medical records.

Billing Questions

What if I can’t pay my bill?
If you are unable to pay your bill you may be eligible for financial assistance. You can obtain this information by contacting our Patient Financial Services department at 802-388-5673 or 802-388-4745.

General billing questions may be directed to the appropriate members of our Financial Services staff per the listing below:

Patient Financial Services 37 Porter Drive Middlebury, VT  05753 PH: 802-388-8808 FAX: 802-388-8322 Chris Cook, Director Porter Financial Services 802-388-5680