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Bridge Pediatrics

Fort Lee 201-585-7337

Bridge Pediatrics

About Us
Providers
Office Info
- Appointments
- Forms
- Policies
- After Hours
- Walk-Ins
- Hospitals
- Insurance
- Well Visits
- Sick Visits
- Emergencies
Services
Resources
- Helpful Links
- FAQs
Patient Education
Location

Forms

Forms & Policies

Complete Patient Forms Before Your Appointment

Prior to your appointment, the forms listed below can be printed for your convenience. Filling them out beforehand will save you time by not having to complete them during your appointment.

If you elect not to fill out these forms ahead of time, please arrive 15 minutes prior to your scheduled time.

Please note we cannot accept electronic signatures on forms that require a signature.

Annual Patient Packet Forms

Adult Patient Registration (PDF)

Annual Consent and Acknowledgement (PDF)

Aviso de Prácticas de Privacidad (PDF)

Child Registration (PDF)

Consentimiento y Reconocimiento Anual (PDF)

Notice of Privacy Practices (PDF)

Pediatric Family Registration (PDF)

Registro de Niños (PDF)

Registro de Pacientes Adultos (PDF)

Registro Familiar Pediátrico (PDF)

Adult Patient Registration (PDF)

Annual Consent and Acknowledgement (PDF)

Aviso de Prácticas de Privacidad (PDF)

Child Registration (PDF)

Consentimiento y Reconocimiento Anual (PDF)

Notice of Privacy Practices (PDF)

Pediatric Family Registration (PDF)

Registro de Niños (PDF)

Registro de Pacientes Adultos (PDF)

Registro Familiar Pediátrico (PDF)

18-year old: ADULTHOOD Letter (PDF)

ABN – Advanced Beneficiary Notice of Noncoverage (Medicare only) (PDF)

ABN – Aviso Anticipado de No Cobertura Para el Beneficiario (Medicare Solamente) (PDF)

ABN - Form Instructions

Advocare Beyfortus Patient Liability Form

Advocare Newborn Insurance Reminder - SPANISH

Authorization to Bring a Minor (PDF)

Cancellation of Prior Health Information Exchange (HIE): Opt-Out (PDF)

Cancellation of Prior SureScripts: Opt-Out (PDF)

Case Registration (PDF)

Estimated Cost: Out-of-Network Services (PDF)

Formulario de responsabilidad financiera del paciente de Advocare

Healow Trifold (PDF)

Health Information Exchange (HIE): FAQs (PDF)

Health Information Exchange (HIE): Opt-Out (PDF)

IMM Withdrawal from NJIIS

Informed Consent: In-Office Procedures (PDF)

Informed Consent: Surgical Procedure or Invasive Treatment Procedure (PDF)

New Jersey Immunization Information System (NJIIS): Consent (PDF)

Newborn Insurance Reminder (PDF)

Notificación de divulgación a profesional/proveedor fuera de la red

Patient Consent to Draw/Test Blood (PDF)

Patient Financial Responsibility (PDF)

Patient Photograph/Video Information Release Authorization (PDF)

Patient Portal: FAQs (PDF)

Patient Portal: Flyer (PDF)

Practice & Payment Philosophy (PDF)

Professional/Provider: Out-of-Network Disclosure Notification (PDF)

Recordatorio de Seguro Para Recién Nacidos (PDF)

Restriction of Disclosure to Health Plan (PDF)

SureScripts: Opt-Out (PDF)

Vaccine Administration Record: Consent/Refusal to Vaccinate (PDF)

Authorization for Use & Disclosure of Protected Health Information (PHI) (PDF)

(Medical Records Release)

Patient Portal Proxy Authorization (PDF)

(18 years or older)

Patient Forms

18-year old: ADULTHOOD Letter (PDF)

ABN – Advanced Beneficiary Notice of Noncoverage (Medicare only) (PDF)

ABN – Aviso Anticipado de No Cobertura Para el Beneficiario (Medicare Solamente) (PDF)

ABN - Form Instructions

Advocare Beyfortus Patient Liability Form

Advocare Newborn Insurance Reminder - SPANISH

Authorization to Bring a Minor (PDF)

Cancellation of Prior Health Information Exchange (HIE): Opt-Out (PDF)

Cancellation of Prior SureScripts: Opt-Out (PDF)

Case Registration (PDF)

Estimated Cost: Out-of-Network Services (PDF)

Formulario de responsabilidad financiera del paciente de Advocare

Healow Trifold (PDF)

Health Information Exchange (HIE): FAQs (PDF)

Health Information Exchange (HIE): Opt-Out (PDF)

IMM Withdrawal from NJIIS

Informed Consent: In-Office Procedures (PDF)

Informed Consent: Surgical Procedure or Invasive Treatment Procedure (PDF)

New Jersey Immunization Information System (NJIIS): Consent (PDF)

Newborn Insurance Reminder (PDF)

Notificación de divulgación a profesional/proveedor fuera de la red

Patient Consent to Draw/Test Blood (PDF)

Patient Financial Responsibility (PDF)

Patient Photograph/Video Information Release Authorization (PDF)

Patient Portal: FAQs (PDF)

Patient Portal: Flyer (PDF)

Practice & Payment Philosophy (PDF)

Professional/Provider: Out-of-Network Disclosure Notification (PDF)

Recordatorio de Seguro Para Recién Nacidos (PDF)

Restriction of Disclosure to Health Plan (PDF)

SureScripts: Opt-Out (PDF)

Vaccine Administration Record: Consent/Refusal to Vaccinate (PDF)

Authorization for Use & Disclosure of Protected Health Information (PHI) (PDF)

Patient Portal Proxy Authorization (PDF)

Assessment Forms

Edinburgh Postnatal Depression Scale (PDF)

(Complete prior to the 1 month checkup)

MCHAT, Revised Follow-Up: Checklist Only (PDF)

(Modified Checklist for Autism in Toddlers - Complete for 18 and 24 month well child checks)

MCHAT, Revised Follow-Up: Packet with Checklist (PDF)

(Modified Checklist for Autism in Toddlers - Complete for 18 and 24 month well child checks)

NICHQ Vanderbilt Assessment: Follow-Up (Parent) (PDF)

NICHQ Vanderbilt Assessment: Follow-Up (Teacher) (PDF)

NICHQ Vanderbilt Initial Assessment (Parent) (PDF)

NICHQ Vanderbilt Initial Assessment (Teacher) (PDF)

PSC-Y Report (PDF)

(Pediatric Symptom Checklist - Youth Report)

Required Forms

Advocare Non-Discrimination Notice (PDF)

Advocare Payer List (PDF)

Explanation of Individual's Right to Appeal Health Insurance Determinations (PDF)

(New Jersey Only)

Grievance Procedure (PDF)

Additional Forms

Allergy Emergency Care Plan

Asthma Action Plan

Athletic Physical Form

New Patient Forms

Authorization for Release of Medical Records

Universal Child Health Record

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