Village to Saugatuck Transfer Application

Saugatuck Pediatrics Transfer Form

If you are a patient of Village Pediatrics LLC and wish to transfer care to Saugatuck Pediatrics LLC, this is the correct form to complete.
Welcome to Saugatuck Pediatrics! We are thrilled to have you join us. We are located at 191 Post Road West, Suite 201, Westport CT, and are a completely independent private pediatric practice.

You will find our policies and workflow are very similar to what you experienced at Village, including our patient EMR/portal, CHADIS screenings, etc.
- Saugatuck Pediatrics will NOT have an administrative fee until 2024, and the 2024 fee will be no higher than the 2023 Village Pediatrics fee.
- You will continue to receive routine and sick care at Village Pediatrics LLC until the opening of Saugatuck Pediatrics LLC at 8:30 am on October 30th, 2023.
THE FORM BELOW IS ONE THE VILLAGE OFFICE ASKS YOU TO USE.

IF YOU DON'T MIND ADDITIONALLY COMPLETING THE REST OF THE INFORMATION ON OUR JOTFORM IT WILL FACILITATE FURTHER IMPORTANT COMMUNICATIONS WITH YOU

Please download the below form, complete and either portal or email it (office@villagepedi.com) back.

Note there is NO FEE for transferring contrary to what is on the form, it is included in your Added Benefits Fee (or not charged if your child has Husky).

THANK YOU!
VILLAGE PEDIATRICS TRANSFER FORM: please download, complete, and either portal or email it (office@villagepedi.com) back to village pediatrics. If the patient is 18 years or older they must complete this themselves.
Insurance: Saugatuck Pediatrics participates with Aetna, Anthem Blue Cross Blue Shield, Cigna, Multiplan, Connecticare and Husky. We are on some specific Empire BCBS plans, please check with your insurance representative to see if we are listed. We will accept United as of January 1, 2024 but will be self pay until then for United patients.

We do not accept ACA (exchange) plans other than Connecticare. Many patients choose to 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.
Parent/Guardian 1/Patient if 18 or older*

First NameLast Name
Parent/Guardian 2

First NameLast Name
Email (best email to send important office communications*
example@example.com
Contact Number (best contact number to send important office communications*
Please enter a valid phone number.
Who was your Village Pediatrics Primary Pediatrician?*
Should be Empty:

Saugatuck Pediatrics Transfer Form