Practice Dynamics

Litchfield Hills Pediatrics
860-567-1263

New Patient Forms must be printed out prior to your first visit

LITCHFIELD HILLS PEDIATRICS

860-567-1263

New Patient Demographic Information

Patient Name (include middle initial):___________________________________________________________

Birth date: ____/____/______ Age: ____________ ( ) Male ( ) Female

Address: _______________________________ City________________________ State______ Zip______

Home Phone: ____/_____/_________ Cell # of Child over 18yrs_______/_____/_______

Parent(s) / Legal Guardian Information

Mother’s Name________________________________ Birth Date____/___/_____S S#_____/_______/_____

Address ( ) same as above if not the same _______________________________________________________

City__________________________ State_________ Zip________

Home Phone_____/______/_______ Cell #_____/______/________ Work #_____/_____/_______

E-mail address__________________________________ Employer_________________________________

Father’s Name______________________________ Birth Date___/_____/_____ SS.#_____/_____/______

Address ( ) same as above- if not the same ___________________________________________________________

City__________________________ State____________ Zip______

Home Phone #____/_____/_______ Cell#______/_________/_________ Work#______/_______/_________

Employer________________________________________ E-mail address________________________________

Insurance Information

Primary Ins.____________________________ ID #____________________ Group#___________

Subscriber/Policy Holder__________________________________ Birth Date___/_____/____

Secondary Ins._______________________________ ID#____________________ Group#___________

Subscriber/Policy Holder_______________________________________ Birth Date____/______/________

Authorization to pay benefits to physician

I hereby authorize payment directly to Litchfield Hills Pediatrics for payment of medical or surgical benefits. I also authorize Litchfield Hills Pediatrics to release said information to above insurance company for such medical or surgical treatments.

Signature of legal guardian/parent_____________________________________

Email non-medical QUESTIONS to:
ltchfldhillspeds@sbcglobal.net

We accept newborns to 5, but if you are an existing patient, we will continue to follow you until you are out of college or 21 years old, whichever comes first. We do not accept new patients over the age of 5 currently
Office Set -up
There are four large comfortable examining rooms, all designed with the comfort of you and your children in mind. Older children have a separate exam room, appropriately furnished with more contemporary magazine and furnishing so they can feel more at ease, and not like they are at a 'baby's' doctor.
We have an infant room, as well as two rooms designed more for the older child.
In the unlikely event there is a prolonged wait time, first and foremost, we apologize, we never intentionally keep anyone waiting, but secondarily, if this inevitable circumstance should affect you, our rooms are equipped with enough play material to keep your child happily engaged.

After Hours Coverage: Provided by 8 local pedaitricians. Someone is available 24 hrs a day to guide you through a problem.
We ask you DO NOT call for medication dosing, prescription refills or non-emergent calls. The call volume at times can be heavy, so calls should be of an urgent need.
Please wait until the office opens to ask non-emergent questions, or refer to a source such as Caring for Your Baby and Young Child From Birth to Five by the American Academy of Pediatrics.

Appointment Scheduling
There are allotted time slots set aside each day for sick visits, so you don't have to go through another night "like last night".
Recognizing even the most organized of us sometimes don't remember to schedule that camp or school physical months in advance, we will try to accomadate an "emergency" physical.
We do call and confirm each appointment 24 hours in advance. Monday appointments are confirmed the Friday before. If the office should be closed for vacation, the opening day appointments are confirmed prior to us leaving for vacation.
If you should have to cancel an appointment, we ask that you do so 24 hours prior to an appointment so that time slot can be allotted to someone else.

Policies:
We are accepting new - older than newborn - patients on a case by case basis. All newborns are accepted. Because of time constraints, Dr. Benzoni does not conduct "meet and greet" visits unless you are pregnant.
Litchfield Hills Pediatrics participates in most major insurance companies.
Co-pay is expected at time of visits. Most major credits are accepted.
Please call 860-567-1263 for an appointment or questions. It is our policy to always have time to see sick patients on the day they call (if it is during office hours)

More Info on Coverage
On call / after hours coverage is provided 24 hours a day, 7 days a week. A board certified pediatrician is always on call to answer questions or to guide you as to where or if you need to bring your child , if your child needs to be seen after hours. When you call our number 860-567-1263, you will be informed of the name of the doctor and the number they can be reached. On Dr. Benzoni's call nights, you will reach her cell phone immediately. If the doctor is engaged at the time of your call (emergencies do arise - such as emergent C-Sec or the on-call doctor is simply not able to get to the phone at the time) there will be an opportunity for you to leave a call back number and message for that doctor.
During our vacations, we arrange for a local pediatrician to see our patients. The communication between our offices is excellent and we will recieve notice of these visits, as well as the plan of action, to complete your child's health record.

Email address ltchfldhillspeds@sbcglobal.net can be used to contact us about a routine, non-emergent, non-confidential matter. It is not set up as a medical advice communication, and an answer may not be returned quickly.

Dr. Benzoni currently is the only doctor in the office. She looks forward to adding an associate soon.

Informative Links
       www.dbpeds.com
       www.contemporarypediatrics.com
     www.aap.org
       www.webmd.com

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