BILLING AND APPOINTMENT POLICIES

FEES:

Charges are determined by the time spent as well as complexity or severity of the problem. A simple fee 

schedule is available upon request. We are concerned about the cost of medical care, and appreciate 

your questions. 

BILLING:

Payment is due at the time of service. Sending you bills increases your cost of care.

We accept cash, personal checks, and MasterCard/Visa. There is a charge for returned checks.

If you have private insurance, we will provide the necessary information for you to submit and be 

reimbursed, but still expect payment at the time of service. We do not accept Medicaid. For Blue 

Choice and Preferred Care, co-pays must be paid at the time of service, but we submit the bill toe the 

company. There will be a service charge for co-pays not paid at the time of service.

If you are the custodian of the child or the child is in your custodial care and you choose to bring the 

child in for care, you are responsible for payment of the bill at the time of service. This includes co-pays 

for Blue Choice and Preferred Care.

CANCELLATIONS/MISSED APPOINTMENTS

We are deeply committed to providing quality care for your children. We also respect your time and 

make an effort to see your child at the scheduled time.

If you are unable to keep your appointment or are going to be late, please let us know as soon as 

possible. This courtesy allows us to serve other patients. Patients who do not cancel will be charged for 

time reserved.

WELL CHILD CARE FORMS

We will generate a copy of school/day care forms at the time of your child’s well visits. Please keep this 

on hand as well as a copy of your child’s immunization record to submit to school or day care as needed. 

Please provide a SASE for other forms that need to be completed.

PRESCRIPTION REQUEST INFORMATION

Please have the following information available when calling the office for prescription refills:

  • Child’s Name 
  • Address 
  • Date of Birth and Age (in years)
  •  Name of Medicine Brand or Generic Quantity 
  • Liquid or Pills or Chewable  Refills 
  • Needed Name, 
  • Address, Phone number, and Fax number of Pharmacy Phone 
  • Phone number to reach you