Lexington Pediatrics Forms & Policies

Downloadable Forms

• New Patient Registration
• Authorization for the Release of Medical Information and Records
• Financial Policy
• Policy for Children Whose Parents are Separated or Divorced
• Referrals and Authorizations Policy**

MyChart Forms

• MyChart Adult Proxy Access Consent Form*  (*Needs to Be Submitted in Person by Adult Patient​)
• MyChart Billing
• MyChart Registration

*Please submit completed forms by uploading to MyChart, faxing to 781-863-2007 or emailing to info@lexpeds.com*

**However, referral authorization policy forms can be emailed to mpescatore@lexpeds.com