Financial Policy (PDF) – This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.
Notice of Privacy Practices (PDF)– Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.
Aviso de prácticas de privacidad
Virtual Visit Policy (PDF) – This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.
New Patient Intake Form
Authorization for Release of Medical Information (PDF)– Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.
Autorización De HIPAA Para Divulgar Información Del Paciente
Authorization and Consent for Treatment (PDF) – All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.
Autorización y Consentimiento Para el Tratamiento
Preferred Contacts (PDF) – Patients are encouraged to complete and return the Preferred Contacts Form but it is not required.
Antietam Pediatrics follows the guidelines of the AAP recommended vaccine schedule.
- Newborn – #1 Hepatitis B given in Hospital
- 1 month – #2 Hepatitis B and PKU
- 2 month – #1 Pentacel, #1 Prevnar 13, #1 Rotavirus
- 4 month – #2 Pentacel, #2 Prevnar 13, #2 Rotavirus
- 6 month – #3 Pentacel, #3 Prevnar 13, #3 Hepatitis B
- 1 year – #1 MMR, #1 Varicella, #4 Prevnar
- 15 month – #4 Dtap, #4 HIB, #1 Hepatitis A
- 2 year – #2 Hepatitis A
- 4 year – Kinrix, #2 MMR, #2 Varicella
- 12 year – Adult Tetanus, #1 Meninigitis, also available Gardasil Vaccine (series of 3)
Lab slip given to test for Lead and Anemia.
Administration of FluMist normally starts mid-August (pending availability) with healthy patients getting it at their check ups. Flu vaccines for high-risk patients (children aged 6 months to 2 years, patients with asthma, heart disease, diabetes, etc.) are normally administered at the beginning of October. Flu clinics are offered at different times, please contact the office for dates and times.
- Pentacel – combination vaccine of DtaP, HIB and Polio
- DtaP – a combined vaccine that protects against diphtheria, tetanus, and pertussis (whooping cough)
- Hep B – protects against Hepatitis B
- Prevnar – protects from pneumococcal disease
- Polio – protects against polio, the vaccine is known as IPV
- Rotavirus – protects against infections caused by rotavirus
- MMR – protects against measles, mumps and rubella (german measles)
- Varicella – protects against varicella, also known as chickenpox
- Hep A – protects against Hepatitis A
- Kinrix – combination vaccine of DtaP and Polio
- Meningitis – protects against bacterial meningitis
- Gardasil – protects against the virus that can cause cervical cancer and genital warts
Reference Websites for Vaccines
External Content Disclaimer
We accept most insurances, but do encourage you to verify that we are a Participating Provider before your visit. Always bring your insurance card with you. Copay is expected at the time of the visit. If you do not have insurance or if your insurance does not cover office visits and immunizations, a payment plan can be set up according to need. This is done for your convenience but ultimately any balances are your responsibility. We accept payment by Discover, Visa and MasterCard. Insurance questions or concerns may be directed to our Accounts Receivable staff by calling 301.393.2600 and selecting option 4.