Office Policies

Co-pays

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 Well Exams at least 24 hours in advance. The NO-SHOW fee for failue to cancel influenza vaccine appointment is $15.00/child. 

Form Fee

A $5.00 Form Fee will be charged if all school and medication forms are not presented to the physician at the time of your child's appointment. If you are in the office for an appointment and forgot your form please ask one our staff members for the form. We have most of them here in our office.

Prescription Refill Request

Please understand that 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. As a courtesy our office will call your home to notify you that the prescription is ready for pick-up. Ordering at the last minute can create delays, so please remember to order early.

Returned Checked Charge

There is a $20.00 Service Charge on all returned checks.

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 physcians 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