Forms & Policies

Parent Forms & Office Policies

All requests will be processed in 2-3 days. Please call the office at 508-746-5900 if you are requesting a same day appointment.

You may download and print any of our forms listed below before coming to our office.  This will get you out of the waiting room and in to see the doctor a lot quicker!  You may either bring them with you to the first visit, or if you wish, fax them to us before your appointment.

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Office Policies

As with any professional office, our goal is to serve our patients efficiently and effectively. In order to achieve these goals, we request that each patient do their part by cooperating with the policies of our practice regarding insurance and payment.

Your insurance plan requires co-pays to be collected at the time of service. We accept Mastercard, Visa, Discover, checks and cash. If you do not pay your co-pay at the time of your visit, we will charge an additional $10 to cover the cost of billing services. Returned checks will be charged a $20 fee.

Please bring your insurance card to every office visit. If the insurance you designate is incorrect, you will be responsible for any balance.

For all services rendered to minors, the adult accompanying the patient is responsible for payment, whether a parent/legal guardian or not. If your child will be brought to our office by a babysitter or other caretaker, please be sure to arrange for payment of co-pay to avoid a service charge if we have to bill you. Credit card payment can be made on the phone prior to the appointment. 

We bill monthly for unpaid balances. If any portion of your bill has been outstanding for greater than 90 days, you will receive a letter stating that if the balance is not paid within 10 days your account will be forwarded to a collection agency.

If you are experiencing financial hardship, please speak with our billing manager so that we can set up a payment schedule. 

Failure to pay an overdue balance on your account, or to set up and abide by an agreed-upon payment schedule, can be cause for dismissal from our practice. 

Self-pay: if your child is not covered by insurance at the time of your visit, or if you are from out of town and we are seeing your child as a service to you, the full amount of the visit is due at the time of service.

The doctors of PPA strongly believe in the importance, safety, and effectiveness of vaccines to prevent serious illness and to save lives. The Centers for Disease Control and Prevention and the Institute of Medicine, among others, have concluded that the recommended vaccinations for children are safe and effective and that serious adverse events are quite rare. We firmly believe, based on all available literature, evidence, and current studies, that vaccines do not cause autism or other developmental disabilities. We firmly believe that all children should receive all of the recommended vaccines according to the schedule published by the Centers for Disease Control and Prevention and the American Academy of Pediatrics (AAP).

Vaccines are one of the most important advances in the history of medicine. They are the best way that parents can protect their children from deadly diseases. The false information spread in recent years regarding vaccines has led to the return of deadly disease. It is our hope to create a relationship of trust and mutual understanding with all of the families that we care for. The schedule put out by the AAP is the best way to keep your child safe. Alternative vaccine schedules, such as delaying or “breaking up the vaccines”, are against our medical advice as providers at PPA and put your child at risk, as well as children who come into contact with them. We have the duty to provide the best evidence-based care for your child, and to protect all of our patients from exposure to preventable diseases.

Taking all of this into account, effective June 1, 2018, we will no longer offer alternative vaccination schedules. We will work with any family whose child is not up to date with their vaccines to become compliant with current recommendations. We will always carefully review any true medical contraindications to vaccinating your child. Thank you for your understanding and for allowing us to participate in the healthcare of your family.

So that we may accommodate the needs of all our patients, it is essential that you make every effort to come to your child’s scheduled appointments and that you arrive on time. Unfortunately, when even one patient arrives late, it can throw off the entire schedule for that session. Therefore, if you are 15 minutes or more late for an appointment, we may need to reschedule your visit. Patients who arrive on time will be seen ahead of those who arrive late.

“No-shows” or appointments canceled with less than 24 hours’ notice will result in a fee of $50 (unless you call us on the day of the appointment to notify us that you are experiencing an emergency). Failure to give us adequate notice that you are canceling an appointment does not allow us to use that time to accommodate other children who are in need of appointments. Please be advised that if your family has 3 late cancellations or missed appointments within a two-year period, it may result in dismissal from our practice.

“Squeezing” in an extra child during a visit: Please know that when you do not inform us in advance that you would like us to examine and treat another one of your children during a scheduled visit, we have not allotted the necessary time to accommodate your request. Therefore, all of the subsequent visits are delayed, thus increasing wait times for the patients with scheduled visits following your appointment and creating a rushed feeling to your visit. If you would like more than one child seen, please inform the nurse when you are making your child’s appointment so that we can accommodate your request. If you request that we examine a child who does not have a scheduled appointment, we will need to register that child, create a visit in the medical record, and charge a co-pay if your insurance company has one.

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.

In order to ensure our adolescent patients receive the best possible medical care, Plymouth Pediatric Associates has adopted an Adolescent Confidentiality Policy of which we would like you to be aware.

Beginning at age 13, each patient will be encouraged to meet privately with their physician or nurse practitioner for a portion of their annual checkup. We believe this privacy helps ensure that the patient provides us with complete and candid information that will assist us in caring for them.

The information discussed by an adolescent and their doctor or nurse practitioner is confidential. We will not discuss this information with anyone without the permission of the patient. While this information is considered confidential, we will always encourage our patients to be open and honest with their parents, and we will do our best to facilitate that communication.

The only time that we would break confidentiality is in the rare circumstance that we think a patient poses a risk to themselves or to another person.

This policy is consistent with Massachusetts state law regarding adolescent confidentiality, as well as the policy of the American Academy of Pediatrics. Research has shown that as many as 35% of middle and high school students have refrained from seeking needed health care because of concerns about privacy. Given how serious the consequences of not getting that healthcare can be, we believe it is essential for us to have this policy.

If you have questions or concerns about this policy please share them with your child’s pediatrician.


At Plymouth Pediatric Associates we are committed to providing your child with the best possible medical care, and this includes treating you and your child with respect, kindness and dignity at all times. If at any time you feel that you or your child have not been treated in this way, please notify either your child’s doctor, our Clinical Manager or our Administrative Manager. We are also committed to providing a safe and supportive working environment for our staff, which means treating them with the same considerations. We fully recognize that under stressful circumstances tempers can flare. However, we will not tolerate any employee being subjected to rude or inappropriate language or behavior. Such behavior will result in dismissal from our practice with 30 days written notice

Cell phones

Please silence your cell phone once you have entered the examination room. If a provider (nurse, physician or nurse practitioner) enters the room and you are talking on your cell phone, please end the call immediately or they will move on to the next patient until you are available.

Photography and Videography (Filming)

We care about the privacy of our patients, families, and staff. Filming and photography is not allowed at Plymouth Pediatric Associates. Taking photos and/or videos of people in clinical areas can be distracting to our staff and therefore cannot be made while care is being provided.