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Call Us:  201.391.2020  •  Fax:  201.391.0265

Forms & Policies

Charges for Forms

In order to deal with the huge number of forms that come into our office there is a $10 fee for all forms not completed at the time of the child’s checkup.

Please leave the forms to be completed in the box provided at our front desk. The box will be checked multiple times throughout the day. Each form will take 72 hours to complete; if the form must be completed in less than 72 hours there will be a fee of $25. You may pick the form up or leave a self-addressed stamped envelope and we will mail it back to you.

On each of the forms leave the first and last name of the patient as well as their date of birth.

We will not fill out any forms for medical clearance if the patient has not had a well-care visit within the past year or if the child has never had a well-care visit at our office.

If you require a New Jersey State Universal School form for patients 11 years and up you must fill out the History Form of the New Jersey Department of Education Annual Exam Form.

As a reminder, at the time of your child’s check-up there is a Universal Form provided free of charge that can be copied and used for school and camp throughout the year.

Thank you for your cooperation.


Chestnut Ridge Pediatrics is and affiliate of BCD Health Partners.

New and Prospective Patients

Before your appointment with us, upon your first visit, we will have you complete new patient forms so that we may obtain all previous records you or your child may have. 

Please fill out a Demographic Information Sheet  for each child, as well as a Medical Insurance Information Form.

Should you have any questions about this process, please contact Ann Marie, our office manager, at (201) 391-2020 .

Parents at Check-Ups

We require the presence of a parent at check-ups for all children under the age of 18. We feel it is very important that we communicate with and counsel both the teenager and the parent at these yearly check-ups. Please bring a completed copy of the History Form of the New Jersey Department of Education Annual Exam Form.

Insurance and Billing

Please visit our Insurance and Billing section for a list of insurance plans that we participate with