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Forms & Form Fees

Need for Office COVID-19 Protection

Dear families,

Main Street Pediatrics, staff, and doctors want to make completed school, camp, and other forms available to you as efficiently as we can. But we also have a real need to protect social distancing, and staff and family health during the COVID-19 epidemic.

Please understand: bringing your forms to the office when you do not have a specific appointment makes it very difficult to maintain orderly social distanced spacing. Please do the following for form processing going forward:

Influenza (‘the flu’) on its own causes substantial prolonged illness and hospitalization each year, including 30,000 to 60,000 deaths in the US on average.

For Routine Forms:

1. Fill out ALL PORTIONS of the forms that ask for patient/parent identification and information.

2. Go online to, click on the “Pay Invoice” button and pay the applicable fee (see below) in advance in this touchless fashion. When the website requests an Invoice Number, you can enter your child’s account number or 0000. (Please note that Medical Assistance, Medicare and MCO members have form fees already ‘included’ in government payments, and you do not need to pay separately.)

3. Enclose a note indicating the form fee has been prepaid.

4. If you do not have a scheduled well visit, MAIL us the forms via US Postal Service. Be sure to enclose a Self-Addressed Stamped Envelope, so that we can mail the form back immediately upon completion.

5. You can bring forms with you to a well visit and you may be able to leave your appoinmtent with the completed forms, as work flow allows.

We do regret to inform you that we will be increasing the standard form fee from the current $10 (at that rate for nearly 20 years) to $15 effective 8/11/2020. (The complex form fee for FMLA, endocrine and similar forms will remain at $20.)

For Form Emergencies: Call us for a form ’emergency’ and we will work with you to deliver the completed form within 48 hours. There is a surcharge of $20 for this special processing.

Please understand: School and Camp forms require a full chart review, recording of health information and vaccine records, and our physicians taking responsibility for school and athletic health and performance during the year.

If the form fee is an excessive burden due to financial stress, please speak with our billing group EHS and your Doctor about options.

Thank you for helping Main Street Pediatrics help you with forms in these stressful times.