Patient Forms – School & Camp
To expedite your first appointment, please arrive a few minutes early to complete registration forms so that we have all the necessary information to treat your child. If your child needs a CT State Health form, we recommend getting the form at your child’s annual physical.
You may download and print the forms from this website, fill them out ahead of time, and bring them with you to the first appointment.
- State of CT – Early Childhood Health Form (yellow form) Early Health Form
- State of CT – K-12 Health Form (blue form) School Age Health Form
- Authorization to Administer Medication Form PDF
- State of CT Camp Form PDF
- Allergy and Anaphylaxis Emergency Plan PDF
- Food Allergies – New Canaan Public Schools PDF
– In order to view or print these forms, you will need Adobe Acrobat Reader installed.
Patient Forms – New Canaan Pediatrics
- Financial Policy
- HIPAA Transfer of Records Request – online form
- HIPAA Transfer of Records Request PDF
- HIPAA Release of Records – Not Transferring –PDF
– In order to view or print these forms, you will need Adobe Acrobat Reader installed.
Notice of Privacy Policies
The Hipaa Notice of Privacy Policies describes how medical information about you may be used and disclosed and how you can get access to this information. Please read this notice carefully and make sure you sign the Acknowledgment of Privacy Policies form that can be accessed on the New Patient page of this website, or ask for the form at the front desk the next time you are in the office.
Notice-of-Privacy-Practices-Updated-April-2021 5
Insurance Information
Please bring a copy of your current insurance card with you to each visit. All co-pays are expected to be paid at each visit. For your convenience, we accept cash, checks and credit cards. Our office will bill your insurance carrier for each office visit. As of January 2020 New Canaan Pediatrics are participating providers with the following carriers:
- Aetna
- Anthem Blue Cross/Blue Shield
- Cigna
- Connecticare (Not the Passage Plan)
- Coventry
- Empire Blue Cross
- First Health
- Multiplan Network
- Oxford
- PHCS Network
- United Health Plan
- Both CT Health Exchange Plans (call for more information)
Please call our office if you don’t see your insurance listed.