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General Forms & Policies

HIPAA Letter to Parents

In order to be compliant with the new HIPAA regulations, we will need to enforce the following procedures:

  • An authorization form will have to be signed by the biological parent or legal guardian (a court order will need to be on file in our office) if someone (for example, a step-parent, grandparent, or other family member, nanny, neighbor etc.) other than the biological parent or legal guardian is:

    1. bringing the child in for a visit;

    2. picking up forms, referrals, etc.

    3. making appointments or calling for medical advice

  • An authorization form will be needed for us to:

    1. Mail/Fax forms to someone other than the parent (ex. camp, school, day care, etc.)

    2. Comply with request for Medication to be given in school.

  • An authorization form will also be needed for us to:

    1. Transfer records to another physician;

    2. Send your child’s records to another persons or businesses not mentioned above (ex: life insurance company)

    3. Discuss your child’s medical care in front of another person beside yourself (the biological parent or legal guardian).

Notice of Privacy Practices

For information on how health information about you (as a patient of this practice) may be used and disclosed, and how you can get access to your individually identifiable health information, please click here

The purpose of this form is to notify you of our office policy in advance.  Please read this carefully and if you have any questions, do not hesitate to ask a member of our staff.


  • Our office participates with many insurance companies.  Should your insurance coverage be with one of these companies, we will bill your insurance company along the guidelines of our contract.  Co-payments, co-insurance, deductibles and non-covered services that have not been satisfied, are the responsibility of the patient.  If your insurance requires you to pay a copayment, it will be due at the time services are rendered.  A $15.00 service fee will be charged in addition to your co-payment if not paid at the time of service or within 5 days.

  • If you have insurance with which we do not participate, payment is expected at the time services are rendered.  We will provide you with an itemized receipt to submit to your insurance.

  • If we are your primary care physician, make sure our name and/or phone number appears on your card.  If your insurance company has not been informed that we are your primary care physicians, you may be financially responsible for the visit.

  • Before making an annual physical appointment, check with your insurance company.  Not all plans cover annual heathy physicals or hearing and vision screenings.  It is your responsibility to know your insurance plan benefits.  If it is not covered, you will be responsible for payment at the time of visit.  Not all services provided by our office are covered by every plan.  Any service determined “not covered” by your plan will be your responsibility.

  • Patient balances are billed immediately upon receipt of your insurance plan’s explanation of benefits.  Your remittance is due within 30 business days upon receipt of your bill.  A $15.00 re-bill fee will be assessed monthly on any outstanding balance greater than 30 days if previous arrangements have not been made.  Unpaid balances may result in the postponement of scheduled well visits.  Any balance over 90 days will be forwarded to our collection agency.

  • If you schedule an appointment for a routine or sick visit and do not cancel 24 hours prior to the appointment, there will be a $30.00 No Show fee added to your account.

  • A $30.00 fee will be charged for checks returned for insufficient funds.  If a check is returned, all future payments must be cash or credit.

  • We charge $15.00 to transfer medical records to another physician.  Our office policy is that you pick these records up and take them to your new physician.

  • If your child has school, camp, or sport forms to be completed, there is a $5.00 charge per form.  Payment must be received prior to forms being returned.  We have a 2 to 3 day turnaround time for forms.

  • If you choose to use your credit card for payment in our office there is a $2.00 fee.

  • During these difficult times of the COVID 19 pandemic, when we are receiving a higher volume of phone calls, often with increased complexity, insurers have informed us that we can, for the first time ever, bill and get reimbursed for these calls. In the past, insurance companies have refused to pay for any of the extensive phone time that pediatricians spend with patients and families.


As we wish to keep our patients and families safe and provide telephone advice, we will start submitting provider phone call encounters to insurance companies. Please review with your specific carriers how these encounters will be handled.

Click Here for Printable Version of Financial Policy

No Show Policy

When patients do not show for scheduled appointment, it deprives our practice of offering that appointment to another patient. Therefore, a $30.00 no show fee will be assessed if  24 hours notice is not given to cancel an appointment.

Form Fee

A $5.00 fee will be assessed for all school/camp forms. Please allow 48 hrs. for completion of forms. Please enclose a self addressed stamped envelope if you wish for us to return the form by mail.

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