Forms & Policies

Practice Philosophy

Falmouth Pediatric Associates is dedicated to the care of children, adolescents and their families. Our care is designed to meet the physical and emotional health needs of all of our patients. This includes pediatric primary care geared towards health promotion, illness prevention, wellness, immunization and illness treatment. Our care is non-discriminatory and our office is handicapped-accessible.

Practice Hours

  • Monday- Friday 9 am- 5 pm.
  • The last appointment is generally scheduled at 4:30 pm.
  • On-call visits are available after hours on weekends when our office is on call for urgent care visits
  • We strive to see acute illnesses in a timely fashion.
  • Well visits are strongly recommended according to the recommended schedule, including annually for children aged 3 years and older.
  • Appointments are currently made by phone or in person. Text message reminders are sent for well appointments.

Specific Policies

  1. Adolescents aged 18 and above may give their own consent for medical care.
  2. By law, we must have the permission of adolescents 18 or older to discuss their care with a parent.
  3. Under age 18, adolescents generally require parental consent before receiving treatment. Exceptions to this include that testing and treatment related to pregnancy and sexual health, for which parents do not require parental consent.
  4. We consider the trust of even our youngest patients to be essential to good care. We will go to great lengths to be truthful to your child.
  5. We offer to continue providing care for your adolescent until his/her 22nd birthday. We recommend beginning the process of finding a new care provider 6 to 12 months prior to this. We are happy to assist with this process.
  6. Under certain circumstances, Falmouth Pediatric Associates may terminate our care relationship with you. This may include:
  7. a. Consistent failure to follow advice
  8. b. Consistent failure to pay bills
  9. c. Significant interaction difficulties, including abusive behavior towards any staff
  10. d. Forging of documents on our stationary
  11. If you need a copy of your/your child’s records, we ask 2 weeks notice and will charge a $10 copying fee.

About medical records

  1. At Falmouth Pediatrics, we are concerned about your family's privacy and are taking steps to help to make sure that it is protected.
  2. Protected information includes anything which identifies you (name, address, phone number, SSN) as well as clinical information.
  3. Our staff has been trained, and our employees understand their obligation to maintain privacy.
  4. When you join our practice, it really helps if we have previous health records before the first visit. Please make arrangements to get those records whenever possible. For newborns, you just give the birth hospital our information and sign a release for us to receive information.
  5. To share any information about you/your child with another individual, practitioner, hospital, or organization, we must obtain written permission from the child's parent or legal guardian. (except for in an emergency). This also includes computer transmissions, faxes etc.
  6. If you require records to be copied or transferred, we also must receive written permission.
  7. Please be sure to give at least 3 weeks advanced notice since we receive many such requests. Written notice also applies to changes in information (for example, surname change). We will attempt to release only required information. Release of very 'sensitive' information such drug testing, HIV testing or psychiatric information, will require a separate consent form.
  8. We are required to release certain information when mandated by courts, public health authorities etc. If there is a parent who should not receive information (for example, in a case of family violence), written notice is also required. Ideally, we should have a copy of a court mandate.
  9. All the businesses with whom we deal- insurance companies, pharmacies etc. will be held to the same standard.
  10. If you have a concern about the handling of a privacy issue, please contact our office manager, Cheryl Smith, or one of the doctors.
  11. The federal government strongly enforces privacy-the fines for breach of confidentiality is severe.
  12. Finally, we ask for your patience and understanding. To ensure privacy is difficult, time-consuming, and often inconvenient. We practice in a small office in a small town, which further complicates matters. However, we believe it is worth the effort.
  13. We welcome your suggestions. You may ask for a copy of this policy at any time.


Demographic sheet


Referral Slip


Permission to Request Records


Permission to Release Records


HIPPA Statement


Family History Sheet