Forms & Office Policies


Registration Forms

Please help us prepare for your first visit by downloading the attached forms. They are available in both Word document and pdf. format.

Download Registration Packet

Notice of Privacy Practices

Patient Authorization Form

Please answer all questions and return the completed forms, together with a copy of the front and back of your insurance card to us.

You may return the forms to us by fax:

Att: Front Desk

Or you may mail the forms to us at:

Park Avenue Pediatrics
1111 Park Avenue
New York, NY 10128

Completed forms can also be brought to the office at the time of your appointment. Please allow a little extra time for us to process your documents and, if necessary, to verify your insurance.

If you are transferring to our practice from another office, please do not forget to bring a copy of your child's medical record and immunization card with you.

Accepted Insurance

  • UMR
  • UHC
  • BCBS (Except YAZ or YCZ)
  • OXFORD (Except Garden or Metro)


For Billing Questions or to Make a Payment, please dial 212-534-3000 and PRESS 4 to speak with a biller

General Information


Our office operates strictly by appointment. We can generally schedule well visit check-ups within the week of your call, between 8am and 6pm.

We know your time is valuable, and we make every attempt to see you at your appointment time, however, unanticipated events and medical emergencies may occasionally disrupt our ability to stay on schedule.

Sick Visit Appointments

Always call for an appointment: Our triage nurse or your doctor will determine if and when your child should be seen, usually on the same day or next. While we try to accommodate walk-ins, these are disruptive and present an inconvenience to other patients. Please help us prepare for your visit by calling and scheduling the visit. If your insurance does not cover emergency walk-in costs, you will be charged for these fees.


Please bring your child's insurance card to each visit. If you have a new insurance, or have received a new card, please arrive 15 minutes prior to your appointment for processing. To avoid waits, you may fax a copy of the new card, or phone us with the information. If we are unable to verify coverage at the time of the visit, we will ask you to pay for the visit out of pocket, and will reimburse you once we receive payment from your carrier. Please remember that it is your responsibility to know the limits of your insurance coverage, to select a PCP, and to answer requests for COB information.


When you make an appointment, the doctor sets aside that time to see your child. If you are unable to keep the appointment, please let us know as soon as possible so that we may make that time available for another patient. We would appreciate 24 hours notice. If a notice is given less than 24 hours, there will be a charge of $50.00.

If you are more than 15 minutes late for your appointment, your appointment may need to be rescheduled, and a NO SHOW fee of $75.00 will be applied.


Co-payments are due at the time of service, as stipulated by your insurance contract. We accept cash, checks and credit cards. We will add a $10.00 fee for processing and postage, if the co-pay is not paid at the time of the visit.

Transfer of Records

Please submit a written, signed request for any copy of your child's medical record. As authorized by New York State law, there is a $0.75 per page fee, plus postage. You can obtain a copy of the immunization record, which is the most important part of the chart, from the NYC Immunization Registry. Please allow 10 business days for the record to be prepared.


School and camp forms are completed strictly, without exception, in the order in which we receive them. Please allow 4 to 5 business days time for us to complete your forms and for them to arrive at their destination. There is a $10.00 charge per form, per child, so we urge you to make and keep a copy of each form to use throughout the year. Please be sure to put the child's name and date of birth on each page, complete and sign the parent portion, and include a stamped, addressed envelope. 


If your insurance company requires a referral to see a specialist, you must make an appointment with your primary doctor first. Your insurance company expects your doctor to assess whether the problem can be treated in our office or if it requires further treatment with a specialist. The doctor cannot make this determination unless the child has been seen for the issue. Please request the referral at least 48 hours prior to the appointment with the specialist.

Written Authorization

It is prudent to have a letter on file authorizing us to treat your child if anyone other than a parent brings the child to our office. This is particularly important if you plan to travel. We cannot treat minors in the absence of a parent without written authorization, except in rare emergency situations.