HERSHEY PEDIATRIC CENTER

441 East Chocolate Ave
Hershey PA 17033

(717) 533 - 7850

Patient Centered Medical Home

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PATIENT FORMS

1. New Patient Form (PDF file)
You can print out and complete in advance of your first office visit or next appointment.

2. Financial Policy for our patients (PDF file)

3. Fee Schedule for office visits (PDF file)

4. Demographics Info Form (PDF file)

5. Regarding Insurance Form (PDF file)

 

6. Important Insurance Information (PDF file) 

7. Receipt of Notice of Privacy Practices and Consent to Bill Insurance (PDF file)

8. Prescription Refills Request
Click on this form to fill out your renewal request on-line or you can call our Prescription Refill Line at (717) 533-0499. Click here for info we'll need when you request a refill.

9. Medical Record Release Form (PDF file)

10. Modified Checklist for Autism in Toddlers (PDF file)

11. Child Development - Ages & Stages Questionnaire 3rd Edition (PDF file)

The forms in PDF file format require Adobe Acrobat Reader to view and print. This software is provided free of charge and you may download the latest version by clicking on the 'Get Acrobat Reader' button below.

Access All Your

Info Online:

 

- Prescription Refills
- Appointments
- Health Records