Policies & Forms


The physicians of Brookville Pediatric and Internal Medicine firmly believe in the safety and effectiveness of vaccines to prevent serious illness and to save lives. We believe that all children and young adults should receive the recommended vaccines on time and accordance with the schedule published by the ACIP and the American Academy of Pediatrics. To ensure the best care and to protect all patients from vaccine-preventable illnesses, we require full immunizations, on time for children seen in our office. New patients who are not up-to-date on their immunizations will be provided with a schedule to get the vaccinations caught up, as part of our care.

New Patients

All Brookville physicians are open to new pediatric patients, we are closed to new adult patients at this time.  To establish care at Brookville, please call our office to set up an appointment, and sign and fax the release of records forms below so we may review your medical history prior to your appointment.

Release of Records to Brookville

Release of Records from Brookville

Financial Policy

FMLA questionnaire

Patient Portal Flyer

Patient Portal User Guide PCC My Kids Brookville

Insurance Participation

Brookville participates with Aetna, Blue Care Network, Blue Cross Blue Shield (PPO, Traditional, MESSA, POS),Cigna (all products except HMO), Physicians Care/ASR, Cofinity/PPOM, Priority Health including Spectrum Health Partners and West Michigan Partners, United Health Care.

Brookville has earned Tier 1 designation with Priority Health.

We also provide care for patients using health sharing ministries, as well as cash-pay.

We are not participating with Medicare and we are closed to Medicaid and MIChild.

Physical Examinations

To ensure the health and well-being of our patients, the physicians at Brookville Pediatric and Internal Medicine have created a schedule for physical exams. Infants should be seen for an initial newborn visit when they are a couple days old and then again at two weeks old if deemed necessary by the physician. After that, the schedule for visits is: 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 24 months, and 30 months.

Children from 3 years of age and up are seen yearly for physical exams to ensure proper growth and development and attainment of appropriate milestones.

Adults should have yearly physical examinations with their primary care physician.

School enrollment and sports clearance forms can be filled out at the time of your visit. Most schools require sports physical forms to be signed on or after April 15 to be considered current for the upcoming school year.

School and Daycare Health Appraisal Form

MHSAA Sports Form

Annual Physical Dual Billing Flyer

 Prescription Refills

Medication refill requests, or prescriptions for over-the-counter medications for HSA reimbursement,  require 72 hours notice. Prescriptions for OTC medications for HSA reimbursement cannot be pre- or post-dated and must be picked up at the office.

Community Resources

Kent County Community Resources

Notice of Privacy Practices

As required by law, our full privacy policy can be downloaded HERE.