Authorization to Treat
If parents are not planning to accompany their child to an office visit, state law requires the parent to send signed authorization with the responsible party. This includes step-parents who do not have legal custody. Without such consent the physicians will not be able to treat.
Authorization To Treat Form
Authorization to Receive Protected Health Information
If parents are not planning to accompany their child to an office visit, HIPAA requires the parent to send signed authorization with the responsible party. This allows our physicians to discuss the child's health with the responsible party authorized to bring them to the office visit.
Authorization to Receive Protected Health Information Form
Prescription Refill Request
For routine refills, please call your pharmacy. Then your pharmacy will call or fax your refill request to our office for approval. Some prescription refills require the authorization of the primary care physician. In this case, please allow our office 5 business days to fulfill your request. Our office will call your home to notify you that the prescription has been authorized. Ordering at the last minute can create delays.
Antibiotics will not be refilled. Please contact our office to schedule an appointment.
Triplicate Refill Request
A triplicate prescription is a prescription written by a provider when prescribing a controlled substance such as an ADHD medication or certain pain medications. To ensure that you do not run out of these important medications, please call 5 days in advance to 438-2300 option 4. There will be a $10.00 charge for same day prescriptions
Information necessary: Name of patient, date of birth, parent's name, daytime phone, name and dosage of medication(s), and prescribing doctor. Thank you for making this process as quick and easy as possible.
A parent or guardian must pick up triplicate prescriptions once the office has notified you that the prescription is ready. Step- parents, grandparents, and other siblings can not pick them up if an authorization is not on file to do so.
The referral office can be reached directly at 559-438-1802 extension 221 if your last name begins with letters M-Z and extension 217 for last names ending A-L. These phone numbers have voice mail at all times so that it is always convenient for you to leave a message if necessary. Your call will be returned within 24 hours.
If your insurance company requires you to obtain a referral before your child sees a specialist or goes for additional testing, here are some things you will need to know:
Routine Referral Process:
- Your primary care physician originates the paperwork to obtain the referral.
- Turnaround time is usually 7-10 days for non-urgent requests.
- Our referrals department will call you with either an appointment date and time or the information needed to schedule your appointment.
- Call the office if you have not received your referral within two weeks.
Urgent Referral Process
- You will usually be in our office when the physician determines your child needs to urgently visit a specialist or go for further testing.
- Paperwork will be originated and approval is usually received in 24 hours.
Parents are required to pay co-pays at each visit. This is a requirement of your contract with your insurance company. We are required to collect these fees by contract.
No Show Fee
A $15.00 NO SHOW Fee will be charged for failure to cancel Sick visits at least 24 hours in advance. Well Exams for children ages Birth-11 years of age a $25.00 NO SHOW Fess will be charged for failure to cancel at least 24 hours in advance. A $50.00 NO SHOW Fee will be charged for failure to cancel Well Exams at least 24 hours in advance for Adolescent Children ages 12 and up. The NO-SHOW fee for failue to cancel influenza vaccine appointment is $15.00/child.
A $5.00 Form Fee will be charged for all school and medication forms that are not presented to the provider at the time of your child's appointment. If you are in the office and forgot your form please ask one our staff members. We have most school forms available. Due to the complexity of FMLA and any State Disability Forms, presented at anytime, a $25.00 Form Fee will be charged.
Returned Checked Charge
There is a $20.00 Service Charge on all returned checks.