Forms and Policies

ADHD Assessment Form

COVID Waiver Form

Credit Card on File Authorization Form

Financial Policy Form

Spring 2024 Updated Form Fee Policy

If you’re switching to our practice and want us to retrieve your records, be sure to download and complete the medical record release form and then email it to info@manhattanvalleypediatrics.com. 

The privacy and security of your medical insurance and records information is very important to us at MVP, so please review the Health Insurance Portability and Accountability Act (HIPAA) Notice below:

HIPAA Privacy Notice and Medical Records Release Form

If it’s your first time visiting us, be sure to download the Patient Registration forms and complete them prior to your visit so that you can save time at the office! Please also be sure to fill out the Financial Policy Form and the COVID Waiver Form. Also, if you’re switching to our practice and want us to retrieve your records, be sure to download and complete the medical record release form and then email it to info@manhattanvalleypediatrics.com. Lastly, the privacy and security of your medical insurance and records information is very important to us at MVP, so please review the Health Insurance Portability and Accountability Act (HIPAA) Notice below:

Patient Registration Form

Financial Policy Form

HIPAA Privacy Notice and Medical Records Release Request

Spring 2024 Updated Form Fee Policy

• Aetna
• Cigna
• Emblem/GHI
• Traditional Medicaid
• Healthfirst and Healthfirst Leaf
• Empire BCBS Healthplus
• Empire BCBS Commercial
• Fidelis
• Oscar
• Multiplan/PHCS
• Magnacare
• United/Oxford
• 1199

How do I enroll to have my credit card stored on file?

If you log into your child’s portal and select “Credit Card on File” from the various portal messages you can review our policy, consent to have your credit card on file and enter your credit card information. Otherwise, when you visit the office, you can complete the form in person.

Why did you introduce credit card on file?

We are trying to streamline our front desk process and help improve our patient experience, having a credit card on file will greatly help reduce wait time and paperwork. Going forward we can automatically process co-pays and payments.

How do I know a payment went thru?

We will send a receipt to your email after we process your payment.

What if I have a large balance?

We will charge any amount under $100, for any larger amount we will contact your directly. If you approve the larger amount, we will process the payment. If you cannot pay the sum all at once then we will work with you to set up a payment plan.

What if you are concerned you were charged an incorrect amount?

If you review your email receipt and think there was an error, please call our office. We are always willing to discuss your bill and payments. If any mistake was made, we can correct the error and refund you immediately.

What if I don’t want to give you my credit card information?

Hopefully the convenience of having a credit card on file will appeal to all of our families. However, if you have any concerns, we are happy to answer any questions , please contact us during regular business hours.

At MVP, our goal is to partner with parents for our children’s health.  We appreciate that children with divorced or separated parents may have unique challenges and we will work with families to best support them.  Please read the policies below so that we can work together in everyone’s best interests:

Divorced/Separated Parents Policy Statement

We at Manhattan Valley Pediatrics believe in evidence based medicine, which has firmly shown the safety of vaccines.

We believe vaccinating children and adolescents is one of our main responsibilities as your pediatrician. In order to best protect our patients, we require families to vaccinate their children.

We strongly encourage following the CDC and AAP vaccination schedule. While we do not believe in any benefit of separating vaccines, we believe in working with families to provide care that is supportive and allows us to grow together.

To this end, we can bring your children back for additional vaccine appointments if you chose to separate vaccines, though we do not encourage this as it leaves your children at risk for serious illness.

If you are unable to commit to completing vaccines by the end of the year in which they are required, we cannot care for your children in this practice. We look forward to working together to keep your family healthy and thriving.

We reserve time slots each day for sick children and do our best to accommodate same-day appointments when your child needs immediate attention.

Walk-in Sick Visits follow the rule of one:
– 1 Child per visit
– 1 Symptom or problem
– Present less than 1 week

Please view our Walk-In Sick Visit Hours here.