Forms/Policies

Below please find copies of forms we use for patient registration. Filling out these forms ahead of time will help save time when you come for your appointment. All the forms below are available in Adobe PDF format. If you haven't installed Acrobat ® Reader ® on your computer, in order to view and print these forms, please download and install the Acrobat Reader from the Adobe website.

If you are bringing/sending ANY medical documentation/records with you for your appointment from a previous provider, please make sure to make copies for yourself. The Maryland Pediatric Group LLC/Pediatric Consultants will not copy any documents provided to our office by patient(s) or parent(s) of patients from a previous provider. If you need copies of previous provider's medical notes, you are expected to call that provider to request them.

  • Upload Documents Here

    To send secure documents to MPG, please upload your document(s) to the appropriate destination below based on your provider.

    If you are uploading documents, please ensure that our office knows what they pertain to. Either send a cover letter with the description of what you are uploading and why OR call our medical call line to let them know you uploaded documents/information. Documents should not be uploaded without our prior knowledge. NOTE: You DO NOT need to call us if you are uploading school/camp forms.  


    **If you are uploading a school or camp form, please read instructions below under the "SCHOOL/CAMP FORMS" tab BEFORE uploading. Incomplete forms or forms without identification cannot be processed.


    For Dr. Murray, Noel Morelli or Kathryn Wendt click here.


    For Dr. LaRosa, Dr. Brinkmann, Dr. Cervenka or Dr. Callender click here.


    For Dr. Winkelstein, Dr. Garza, Dr. Donahoo, Dr. Bhatt or Stephanie Eyler click here. 

  • Administrative Forms

    To fill out forms and submit electronically, please use the links below:

    HIPAA Privacy Notice

    Registration Form

    Registration Form for Additional Children

    Consent for Treatment of Minor

    Preventative Medicine Billing Policy


    To print and handwrite forms, please use the links below:

    HIPAA Privacy Notice

    Registration Form

    Registration Form for Additional Children

    Consent for Treatment of Minor

    Preventative Medicine Billing Policy

  • School/Camp Forms

    Steps for Form Completion


    1. Complete the parent portion of your form. Be sure to sign where indicated

    • Completing these areas on the forms helps us ensure utmost accuracy and completeness of forms. Incomplete forms cannot be accepted

    2. Complete MPG's parent questionnaire electronically. This will automatically be submitted to MPG and matched with your form. (PDF versions below if you prefer to mail it in with your form)


    3. Upload (by navigating to the UPLOAD DOCUMENTS HERE tab above), mail in, or drop off your form to MPG.

    • If mailing your form please send the form with all of the necessary parent information completed

              - Failure to fill out the form completely will delay processing time since we will have to mail it back to you for completion


    4. To pay your form fee and to expidite this process, please click the PAY MY BILL option on the top of this webpage. Follow the prompts to complete payment. Please indicate in the memo field that this is payment for your child(ren)'s form or forms. **Fees for forms are collected on a PER FORM basis not per child or per page (Example 1: one child has a form for school and a form for camp, needed in the 14 day turnaround time, the fee would be $40. Example 2: one child has a form for school that includes 3 pages and an immuinzation record, needed in the 14 day turnaround time, the fee would be $20)

    • Standard Form: $20

              - 14 Business Day Turnaround

              - Standard forms will be posted to our portal once completed, please call our office if you need access to the portal.

                   - If you need to pick up your form, it can be processed urgently for $40 and picked up within two business days.


    • Urgent Form: $40

              - 2 Business Days

              - We will call you when your form is completed to arrange making this form available on the portal or available to pick up


    • NOTES:

              - All account balances must be paid in full prior to forms being completed

              - Forms that require prescriptions to be sent to a designated pharmacy will have an additional $20 added to the above fee. 


    Questionnaire for Parents (PDF)

  • Records Request

    If you require a copy of any portion of your child's record please fill out the Authorization to Release Medical Records form below. Please note that we require at least 5 business days for completion of these requests. All record requests must be accompanied by a completed form. Please note, fees for postage/handling and for off-site medical records apply.

    (If you require a school or camp form to be filled out, please view the School/Camp Form tab for instructions and DO NOT fill out a record request)


    To fill out forms and submit electronically, please use the link below:

    Authorization to Release Medical Records


    To print and handwrite forms, please use the link below:

    Authorization to Release Medical Records (PDF)

  • Referrals

    If your insurance requires a referral authorization, you must obtain that authorization from our primary physicians prior to going to your appointment except in emergencies.


    Please call our office at least seven business days in advance to allow us to assure that your documentation is complete. Emergencies will be handled accordingly.

  • Financial Policy

    The Maryland Pediatric Group, L.L.C. would like to take this opportunity to inform you of our practices updated financial responsibilities. These policies protect our ability to successfully provide care and responsibly adhere to mandated guidelines established by patient selected and contracted insurance companies. Your familiarity with the following policy statements and your willingness to comply, are imperative for the delivery of our pediatric care. You will be asked to review this information and sign it at your next visit.


    MISSED APPOINTMENTS/LATE CANCELLATIONS:


    Missed appointments represent a cost to us, to you and to other patients who could have been seen in the time set aside for you. Cancellations are requested 24 hours prior to the appointment. We reserve the right to charge for missed appointments or appointments not cancelled within 24 hours.The fees are listed below:

    • $25 for a single missed appointment Monday through Friday 8 a.m. to 4:30 p.m.
    • $50 for a single missed appointment during our extended hours 7 a.m. to 8 a.m. Monday through Friday, and for all Saturday appointments.
    • $100 for double appointments
    • $150 for triple appointments

    Appointments that are scheduled on the same day and cancelled on the same day or not attended (no show), are subject to the same fees as above.

    Multiple missed appointments, or failure to comply with other MPG policies, may result in dismissal from the practice.


    To fill out the form and submit electronically, please use the link below:

    Financial Policy Disclosure and Agreement


    To print and handwrite the form, please use the link below:

    Financial Policy Disclosure and Agreement

  • FSA

    The Maryland Pediatric Group clinicians will not write prescriptions for over the counter medications to be used for Healthcare Flexible Spending Account (FSA) refunds. The administrative cost of doing so is prohibitive. Please contact the practice administrator with further questions or concerns.

  • Vaccination Policy

    Based on all available literature, evidence and current studies vaccines have been proven to prevent serious illness and death.  All children and young adults should receive all of the recommended vaccines according to the schedule published by the American Academy of Pediatrics unless there is a medical contraindication.

     

    Vaccinating children and young adults is the single most important health promoting intervention we perform as health care providers, and that you can perform as parents or caregivers. 

     

    Vaccinating on schedule with currently available vaccines is the safest thing to do for all children and young adults. Anything different is dangerous and puts our patients at unnecessary risk. 

     

    It is for this reason that we have a strict vaccination policy at our practice.  If you do not intend to follow the current vaccine schedule, we will ask you to find another health care provider.

  • Privacy Policy

    TRUSTED DOCTORS Website Privacy Policy

    Trusted Doctors MSO


    WEBSITE PRIVACY POLICY


    The Maryland Pediatric Group, LLC

    www.mdped.com

    Effective Date: June 17, 2026 | Last Updated: June 17, 2026


    1. About This Policy


    The Maryland Pediatric Group, L.L.C. is a pediatric medical practice located at 10807 Falls Road, Suite 200, Lutherville, MD 21093. We are committed to protecting the privacy of visitors to our website, www.mdped.com(the "Site").


    This policy explains what information we collect when you visit our Site, how we use it, who we share it with, and what rights you have. It covers data collected through this website only. It does not govern the health information we collect during your care, that information is handled in accordance with our HIPAA Notice of Privacy Practices, which is available here.


    2. Information We Collect on This Website


    2.1 Information You Provide Directly


    We collect information you voluntarily submit through forms on our Site, including:


    • New patient enrollment forms (demographic information, insurance details, emergency contacts)
    • Contact and general inquiry forms (name, email address, phone number, message content)

    2.2 Information Collected Automatically


    When you visit our Site, certain technical information is collected automatically by our web server and any analytics tools we use:


    • IP address and general geographic location (city/region level)
    • Browser type, operating system, and device type
    • Pages visited, time spent on each page, and links clicked
    • Referring website (the site you came from before visiting ours)
    • Date and time of your visit

    Note: We do not use Google Analytics, Meta Pixels, or other third-party behavioral tracking tools without first obtaining your consent through our cookie consent banner.


    3. How We Use Your Information


    We use the information collected on this website only for the following purposes:


    • Communications: to respond to questions or messages you send through our contact forms.
    • Payment processing: to facilitate online co-pay or bill payment through our third-party payment partners.
    • Site operation and security: to maintain the security and functionality of our website and detect unauthorized activity.
    • Legal compliance: to comply with applicable federal and state privacy laws.

    We do not sell your personal information. We do not use information collected through this website for marketing or advertising purposes without your explicit consent.


    4. Third-Party Services and Vendors


    Our website integrates with certain third-party service providers to enable appointment scheduling, patient intake, payment processing, and portal access. Each of these vendors has its own privacy policy, and where they handle your health information, they are bound by HIPAA Business Associate Agreements with our practice.


    • Phreesia: Patient intake system collects demographic, insurance, and pre-visit health history information before your appointment.

              - Phreesia Privacy Policy: phreesia.com/legal/privacy-policy

    • InstaMed: Online payment processing handles co-pay and bill payments. InstaMed does not store full payment card numbers on our behalf.

              - InstaMed Privacy Policy: instamed.com/privacy-policy

    • Bridge Interact (Patient Portal): Patient portal provides secure access to health records, appointment requests, test results, and secure messaging with your care team

              - Bridge Interact Privacy Policy: mdpedsgroup.portal.officepracticum.com/auth/privacy-policy


    5. Cookies and Tracking Technologies


    5.1 What Are Cookies


    Cookies are small text files placed on your device when you visit a website. They allow the site to remember preferences and recognize returning visitors. We use cookies only for the purposes described below.


    5.2 Strictly Necessary Cookies


    These cookies are required for the Site to function and cannot be turned off. They include session authentication cookies used when you log into the patient portal and security tokens that protect form submissions from unauthorized use. No consent is required for these cookies.


    5.3 Analytics and Performance Cookies  [OPTIONAL: include only if you use analytics]


    We use may use analytics to understand how visitors use our Site. This tool collects anonymized data about pages visited and time spent. It does not collect your name, email address, or any health information. You may decline these cookies using our cookie consent banner.


    5.4 YouTube Video Embeds


    Some pages on our Site include embedded YouTube videos. We use YouTube's privacy-enhanced mode (youtube-nocookie.com), which means YouTube's servers are not contacted and no cookies are placed on your device until you actively choose to play a video. Once you press play, YouTube's privacy policy applies.


    YouTube / Google Privacy Policy


    5.5 Google Maps


    Some pages on our Site include an embedded Google Map to display our office location. Google Maps may set cookies and collect your IP address when the map loads. If you prefer, you can use the "Get Directions" link instead, which opens Google Maps in a new tab only when you choose to do so.


    Google Privacy Policy


    5.6 Managing Cookies


    You may decline non-essential cookies at any time using the cookie consent banner on our Site. You may also configure your browser to block or delete cookies, though doing so may limit certain functionality. Most browsers allow you to manage cookie settings through their privacy or security settings menus.


    6. Children's Privacy


    Our Site is intended for use by parents and legal guardians of our pediatric patients. It is not directed at children under the age of 13, and we do not knowingly collect personal information directly from children under 13 through this website.


    In accordance with the Children's Online Privacy Protection Act (COPPA), if we become aware that we have inadvertently collected information from a child under 13 without verified parental consent, we will delete that information promptly.


    If you are a parent or guardian and believe your child has submitted personal information through our Site without your knowledge, please contact us at PODMAPPT@mdpedgrp.com and we will remove the information as quickly as possible.


    All patient health records for minor patients are maintained in our clinical systems under the direction of a parent or guardian and are governed by our HIPAA Notice of Privacy Practices, not by this website policy.


    7. Your Privacy Rights


    7.1 Rights for All Visitors


    Regardless of where you are located, you may contact us at any time to:


    • Request access to the personal information we have collected through this website about you
    • Request correction of inaccurate information
    • Request deletion of your information, subject to certain legal limitations
    • Withdraw consent you have previously given for optional cookies or communications

    7.2 Additional Rights for California Residents (CCPA / CPRA)


    If you are a California resident, you have the following additional rights under the California Consumer Privacy Act (CCPA) and the California Privacy Rights Act (CPRA):


    • Right to Know: You may request a detailed list of the categories of personal information we have collected about you, the sources from which it was collected, the purposes for which it was used, and any third parties with whom it was shared.
    • Right to Delete: You may request that we delete personal information we collected from you, subject to certain exceptions permitted by law.
    • Right to Correct: You may request that we correct inaccurate personal information.
    • Right to Opt Out of Sale: We do not sell your personal information and have not done so in the preceding 12 months.
    • Right to Non-Discrimination: We will not discriminate against you for exercising any of these rights.

    To submit a California privacy request, see Section 9 below. We will respond within 45 days. If we need additional time, we will notify you within the initial 45-day period.


    7.3 Additional Rights for EEA and UK Residents (GDPR)


    If you are located in the European Economic Area (EEA) or United Kingdom, you have the following rights under the General Data Protection Regulation (GDPR):


    • Access, rectification, erasure (right to be forgotten), and restriction of processing of your personal data
    • Data portability — the right to receive your data in a structured, commonly used format
    • The right to object to processing based on legitimate interests
    • The right to withdraw consent at any time, where processing is based on consent
    • The right to lodge a complaint with a supervisory authority in your country of residence

    Our legal basis for processing data collected through this website is your consent (for optional features and cookies) and our legitimate interest in operating a functional, secure website and responding to your inquiries.


    To exercise any of these rights, please see Section 9 below. We will respond within 30 days.


    8. Data Retention


    We retain personal information collected through this website only as long as necessary for the purposes described in this policy or as required by law.


    • Form submissions (contact, info and career forms): retained until the inquiry is resolved, then securely deleted.
    • Cookie consent records: retained for 12 months from the date of consent.

    9. How to Submit a Privacy Request


    To exercise any of the rights described in Section 7, please contact us using one of the methods below. We will verify your identity before processing your request and will respond within the timeframes required by applicable law (30 days for GDPR, 45 days for CCPA).


    Contact Method Details

    Email (preferred) PODMAPPT@mdpedgrp.com

    Mail Attn: Privacy Officer

    The Maryland Pediatric Group, L.L.C.

    10807 Falls Road, Suite 200

    Lutherville, MD 21093

    Phone 410-321-9393


    To protect your privacy and security, we will verify your identity before processing any data access, correction, or deletion request. You may be asked to provide your name, date of birth, and the email address or phone number associated with your inquiry.


    10. Links to Third-Party Websites


    Our Site may contain links to external websites, including our patient portal, payment platforms, and other resources. We are not responsible for the privacy practices or content of those external sites. We encourage you to review the privacy policy of any third-party site you visit.


    11. Changes to This Policy


    We may update this policy from time to time to reflect changes in our practices, legal requirements, or the features of our website. We will post the updated policy on this page with a revised "Last Updated" date at the top. For material changes, we will provide more prominent notice at our discretion. Your continued use of our Site after any changes constitutes your acceptance of the updated policy.


    12. Contact Us


    If you have questions about this policy or about how we handle your personal information, please contact us:


    Privacy Officer / Office Manager

    The Maryland Pediatric Group, L.L.C

    10807 Falls Road, Suite 200, Lutherville, MD 21093

    410-321-9393

    PODMAPPT@mdpedgrp.com