Established Patient Forms – Yearly Update & Teen Portal Access Form

Yearly Update Form – Like most offices, we need to make sure we have the most accurate information. Please complete these forms prior to your child’s first appointment of 2024. We hope this form is easier by allowing multiple names on one form. 

Yearly Update Form – 2024 (via online form submission) 

PDF of form here: YUF 2024 (Fillable PDF)

18-20 Year Old Yearly Update Form – 2024 (via online form submission)

PDF of form here: 18 Yr_Patient Forms_2024 (Fillable PDF)

Teen Patient Privacy Notice & Portal Access Form – An informed teen is a healthy teen! Please read over this form and you and your teen (age 13+) can decide together who has access (teen or teen + parent/guardian) and what type (Complete or Restricted). 

PDF of form here: Teen Privacy and Portal Form (Fillable PDF)

Email completed and signed forms to: forms@gatewaypediatrics.com

 

Attention Parents Wishing to Transfer to Gateway Pediatrics

Effective September 1, 2023: We are currently NOT accepting New Patient transfers. We are only accepting Newborns (once discharged from the hospital) and Siblings of Established Patients (e.g. Adoptive Siblings, Siblings by Marriage, etc.) If you are outside of these two categories and submit paperwork, it will not be processed. 

 

New Patient Forms

In order for your child(ren) to be seen, you will need to fill out the “New Patient Paperwork” packet for each child (either through our online form or fillable PDF). In addition, if your child is coming from a different pediatrician or healthcare provider, a “Medical Record Release Form” will also need to be filled out for each child. You may download the following PDF forms or pick them up at our office. The PDF files marked “Fill & Sign” are made so you can type right on them. You can also submit forms electronically via online form submission! (See below.)

(Adobe Acrobat required.) – click here to go to Adobe to download Acrobat. (You will leave our site.)

New Patient Paperwork (via online form submission)

New Patient Paperwork (Fill & Sign)

Medical Record Release Form (via online form submission)

Medical Record Release Form (Fill & Sign)

Notice of Privacy Practices

Consent to Treat

Consent to Treat – Telemedicine

For patients with Commercial Insurance, please read our Credit Card on File Policy prior to your first appointment:

Gateway Pediatrics Credit Card on File Policy

Credit Card Authorization Form (Fill & Sign)

FORM BEST PRACTICES:
Open the form in Adobe Acrobat, not in your browser. This will allow you to see all the required fields and add your electronic signature. If you are unable to sign electronically: Print, sign, and email us a photo of each form, please be aware that if the image is unclear (or fingers are in the way) it may delay processing. 
***PLEASE EMAIL TYPED PDFs OF THE FORMS. IF YOU SEND A PHOTO AND IT IS NOT CLEAR, OR IF FORMS ARE UNSIGNED, WE MAY ASK YOU TO COMPLETE THE PAPERWORK IN OUR OFFICE***

Email completed and signed forms to: forms@gatewaypediatrics.com

Please mail or drop off forms to:
Gateway Pediatrics, LLC
1415 Wesley Drive
Salisbury, MD 21801

You may also fax them to our secure fax server at 410-912-4202.

If you have any questions, please call our office at 410-912-7000.


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