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Welcome to the VAPG Forms page

In order to help reduce waiting time at your appointment, please complete the forms below that correspond to you and bring them with you to your appointment. Thank you

Most of the Forms you will need for Virginia Pediatric Group, Ltd services are available on this site. You can complete the majority of forms using an Adobe® Acrobat Reader, which can be downloaded free of charge. Most forms posted on this site can be completed in this manner. You must then print your completed form and please bring this with you to your appointment.

We are making every effort to offer all of our forms in an Adobe® Acrobat on-screen fillable format. However, new or revised forms may not be available in this format initially. As soon as a fillable version of these forms becomes available, we will post it on this site.

If you cannot use Adobe® Acrobat, you may obtain forms for use by contacting Virginia Pediatric Group.

Patient Registration Form:

You need to fill this form if:

  • You are new patient to our practice.
  • Your address has changed since your last visit.
  • Your insurance information has changed since your last visit.
  • You have not been to our practice in a year.
  • Any of your employment information changes.
Please bring the completed registration form and your insurance card with you to your visit.

VAPG Registration Form

Credit Card Payment Processing Form:

Please complete all blanks and fax or mail the form to our office at the following address:

Virginia Pediatric Group
3020 Hamaker Ct
Suite 200
Fairfax, VA - 22031
Fax to: (703) 280-9350

VAPG Credit Card Payment Processing Form

Medical Record Request Form:

It is illegal to request patient medical records, if you are not the parent or legal guardian

Please complete all blanks and fax or mail the form to our office at the following address:

Virginia Pediatric Group
3020 Hamaker Ct
Suite 200
Fairfax, VA - 22031
Fax To: 703-280-9350

VAPG Medical Record Request Form

Referral Request Form:

If your child needs to see a specialist, follow these instructions to process a referral:

  • Determine if your insurance company requires you to have a referral for the problem that your child has. PPOs do not need referrals.
  • Obtain approval from your PCP (clinician) for the referral.
  • Make an appointment with the specialist.
  • Click on Referral Request form below, input the information requested, and click on submit.
  • It takes approximately 5 - 7 business days to process your referral. Most referrals are now electronic, so there is no hard copy. Your specialist will receive the referral via fax.
  • Alternative to submitting the form online, you can call the Virginia Pediatric Group referral line at and leave us all information required.
To contact referral department Call (703) 573-2432 Option 7
VAPG Referral Request Form

There are many common myths about the referral process that we would like to highlight for you:

Myth: Your Virginia Pediatric group Primary Care Physician (PCP) or nurse practitioner notifies the Virginia Pediatric group referral coordinator or your insurance company of your need to take your child to a specialist.
Fact: No, the providers do not notify the referral coordinator or your insurance company. We rely on you to provide the information about your referral since frequently the specialist whom you will see or the time of the appointment changes. Please fill out our referral request form so that we have all of the information that we need to process your referral. You can submit this form to us over our web site or you can call our referral hot line (703) 573-2432 Ext 418, to leave the information. Please allow 5 - 7 days for processing.

Myth: Your Virginia Pediatric group PCP or nurse practitioner knows which specialists take your insurance.
Fact: With so many insurance companies, it is impossible for your Virginia Pediatric group PCP or nurse practitioner to know which specialists are approved by your company. Make sure that you ask the specialist's office if that specialist takes your insurance when you set up your appointment. If the specialist does not take your insurance, you may be subject to "out of network" costs.

Myth: You will receive a copy or a phone call, when your referral is processed.
Fact: No, please contact the specialist office 3 business days before your appointment. Your referral will be faxed directly to your specialist office.

Myth: Your referral was processed so you won't be getting bills from the specialist's office.
Fact: Our office can process a referral, but an insurance company can still deny coverage. Each company has different benefits and different plans within that company. What a company covers under your plan is based on your individual or group policy. It is your responsibility to know what coverage your insurance company allows. You may also be responsible for co-payments or deductibles. Call your insurance company to be sure.

Myth: The specialist's office knows you will need a referral and will obtain one for you.
Fact: Again, with so many different insurance companies and plans, it is difficult to know for certain who needs a referral and who does not. In general, if you have an HMO, you will need a referral. On occasion, the specialist's office will call Virginia Pediatric group for a referral, but do not depend on it. You are ultimately responsible and will have to pay for specialist's charges if you do not obtain a referral.

Prescription Refill:

You can submit prescription refills online. Click below to be connected to the link. We will call you if the refill is not approved.
VAPG Prescription Refill Request Form

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I am a board certified Physician Assistant who has worked in pediatrics for the last 15 years. ...more
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