| San Francisco Office | Mill Valley Office | Billing Office |
| Fax – (415)752-5391 | Fax – (415)388-7136 | Fax – (415)668-6627 |
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If you are coming into our office for a visit for the first time, please complete the following forms and bring them with you to your first visit. If a sibling already comes to our practice, we still need these forms completed for the new patient. Please remember to bring an insurance card and a photo ID as well.
First Visit to Golden Gate Pediatrics Form
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If you are submitting a form to be completed by one of our physicians, please fill out the following form and submit it with the form you need completed by your physician. This will assist us in accurately completing the form submitted to us. Please make sure you have completed all sections of your form that are supposed to be fill out by the parent or student before submitting your form to our office.
There is a $15 fee for all forms that the physicians need to complete. Due to the quantity of forms we receive, there is usually a five day turnaround time. If the form is needed sooner, the fee to complete it within 24 hours is $25.
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If your child is coming in for an immunization and a parent or legal guardian will not be present, please print and fill out the following form giving our office permission to administer the appropriate vaccine(s).
General Vaccine Administration Permission Form
Injectable Flu Vaccine Administration Permission Form
Nasal Flu Vaccine Administration Permission Form
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If you would like to request a copy of a patient’s records for yourself or to be transferred to another doctor, please complete the following form and submit it to the appropriate office with $25.00. If the patient is over 18 years of age, he/she must sign the release themself.
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If you would like a copy of a patient’s immunization record, please fill out and submit the following form to the appropriate office. There is no fee for this.
Immunization Record Release Request Form
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If you have a change of insurance, please fill out the following form and fax it to our billing office, (415)668-6627, with a copy of the front and back of your current insurance card. You also can drop it off at either of our offices.
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If you have an address change, please fill out the following form and either mail it or fax it to the appropriate office.
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If we do not have a signed HIPAA Policy on file, we will need one completed before we can release any information regarding a patient to anyone. Please fill out and submit the following form in its entirety.