New Patient Transfer Application

If you are interested in making Saugatuck Pediatrics your child/children's medical home, please complete this survey to ensure we are a good match for your family. Please also see the “Are We a Good Fit” page on our website, www.saugatuckpeds.com, to review our office policies.

Please be aware that submitting this application in no way guarantees a spot in the practice, as we are limited in the number of patients we are able to accept at this time.

Parent 1*

First NameLast Name

Email*

example@example.com

Best Contact Number*

Please enter a valid phone number.

Parent 2

First NameLast Name

Are you moving from out of the area?*

What practice are you transferring from? *

If coming from a local practice, why are you looking to leave?*

Current and previous specialists your child(ren) have seen in the last 5 years:

Please list your child/children’s names and ages. Please note that if you are interested in transferring into our practice, you must transfer all children as Saugatuck Pediatrics LLC does not split care of siblings with other practices.

How many children do you have?*

Child's Name*

First NameLast Name

Age*

Child's Name*

First NameLast Name

Age*

Child's Name*

First NameLast Name

Age*

Child's Name*

First NameLast Name

Age*

Child's Name*

First NameLast Name

Age*

Insurance: Saugatuck Pediatrics participates with Aetna, Anthem Blue Cross Blue Shield, Cigna, Multiplan and Connecticare. We are on some specific Empire BCBS plans, please check with your insurance representative to see if we are listed. We will accept United healthcare as of January 1, 2024, but United patients would be self pay until then. We do not accept ACA (exchange) plans other than Connecticare. Many patients do come to us out of network. Please note that patients who are out of network are expected to pay for the full cost of the visit at the time of service.*

Are you willing to adhere to the Academy of Pediatrics and CDC recommended vaccine schedule (note that we do not skip, delay, or separate vaccines):*

We sometimes provide needed services that are either not fully covered or not covered by some insurers. Examples include hearing and vision screening, doctor visits that insurers believe are for “mental health” reasons, and some in-office labs. In such cases, are you willing to pay for these services yourself?*

Have you read and do you agree with the “Are We a Good Fit” checklist?:*

Saugatuck Pediatrics LLC charges a modest per child fee (our Annual Administrative Fee) to cover a variety of administrative services not covered by insurance. This fee also allows our practice to remain small and personalized. Are you comfortable paying this fee yearly?*

Whom can we thank for referring you?

Any further comments?

By checking this box you agree to receive text messages from Saugatuck Pediatrics, you can reply stop to opt-out anytime.

Saugatuck Pediatrics - New Patient Transfer Application