Patient Forms

pediatric medical formsClick on the icons below to print the new patient forms that should be completed and brought to your first appointment with your insurance card. Please note: some of the forms are two-sided.

Registration Form

Privacy Statement Form

Privacy Consent Form

Authorization to Release Protected Health Information Form

Authorization to Seek Medical Care Form

Authorization for Step-Parent to Seek Medical Care Form

Health History Form

Contact Information

Westerville Office
495 Cooper Road, Suite 325
Westerville, OH 43081
Phone: 614-508-2223
Fax: 614-508-2233

Sunbury Office
450 South Miller Drive, Suite 100
Sunbury, OH 43074
Phone: 740-965-6369
Fax: 740-965-6371

 Attention Patients with CareSource or Molina!!!

In order for us to provide appropriate follow-up for laboratory results, urgent care visits and referrals, it is important that you make sure that one of our physicians is designated as your child's caregiver. We encourage you to contact your case manager or your insurance company directly (CareSource 1-800-488-0134, Molina 1-800-642-4168) and ask if your primary care physician be changed to Dr. Leymaster, Dr. Wodarcyk or Dr. Yaw.

If you have private insurance and your policy requires a designated primary care physician, please contact your insurance company directly to ensure that one of our physicians is listed on your card.

 

Routine Urinalysis Update

In accordance with the recommendations from the AAP Section on Nephrology Executive Committee [Committee on Practice and Ambulatory Medicine and Bright Futures Steering Committee. Pediatrics routine urinalysis testing will no longer be required for asymptomatic patients during well-child examinations at our office.