Download Patient Forms
Before your appointment with us, quickly and conveniently access patient forms from our practice.
To view the forms listed below, you will need to download Adobe Reader. Please bring your completed forms with you to our office at the time of your visit.
- Patient Registration Form
- Patient Authorization Form
- Patient Authorization Personnel
- Medical Documentation Form
- Medical/Family History Questionnaire
- Office Policy Form
- NICHQ Vanderbilt Assessment Scale – Parent Information
- NICHQ Vanderbilt Assessment Scale – Teacher Information
- As part of our contract with the insurance companies, we are required to collect co-pays at the time of the visit. If you are not able to pay the copay, it may be necessary to reschedule the appointment.
- Full payment is due at the time of service for self-pay patients.
- We understand that there may be extenuating circumstances where full payment for balances may not be possible. In these situations, we ask that you contact our office manager to set up monthly payment arrangements. We may require a credit card on file (in our secure patient payment portal) for monthly payment plans.
- If you have an overdue balance, and you have not made financial arrangements, we may need to reschedule your appointment.
- Unresolved, outstanding balances (where financial arrangements have not been made) may result in dismissal from the Practice.
- We accept Visa, Mastercard, American Express and Discover credit cards as well as personal checks.
- Returned checks will be assessed a $25.00 fee.
Missed appointment charges
We do charge for missed appointments. There is a $35 fee for a routine prior scheduled, missed or cancelled appointment with less than 24 hours notice. Illness visits should be cancelled more than 4 hours in advance. There is a $15 fee for missing a vaccine only visit with one of our medical specialists. Late arrivals may need to be rescheduled.
- If you arrive 15 minutes late (or later) for your appointment, we will do our best to accommodate you. However, on certain days, it may be necessary to reschedule your appointment.
- We participate with many insurance plans, however, coverage varies widely and part or all of your services may not be covered by your plan. If we participate with your insurance plan, we will submit the claim for you. It is your responsibility to provide accurate and timely insurance information to our Practice. Inaccurate or untimely insurance information may result in denial or non-coverage of services and will become the financial responsibility of the guarantor.
- If we are designated as your primary care physician (PCP), please ensure that our name and phone number appear on your insurance card. If your insurance plan requires a PCP designation, and we have not been designated, we may need to reschedule your appointment or you may be responsible for charges associated with the visit. Also, please be aware that not all plans cover annual health (well) physicals, sports physicals, or hearing and vision screenings. If services are not covered, you will be responsible for payment.
- It is your responsibility to understand your benefit plan, including covered services and participating laboratories.
We want you to call. We do not want anyone sitting at home (or at the office) worrying about something, and not calling us. There is NO such thing as too small of a question, and we want you to feel comfortable with all issues regarding your child and family. Also we do not want you to take your child to an urgent care or an Emergency room unless needed.
Therefore, we try to make ourselves as available as possible by opening the office at 9:00 AM each day and returning your telephone calls throughout the day. It is preferred that you call early in the day if possible in order to give us time to return your call. If your call involves a non-urgent issue, particularly one that may require more lengthy discussion, please provide an alternate number to return your call later in the day. If you will be changing location or telephone availability within a few hours of calling us, please let us know.
After hours and weekend phone calls made to the office are received by our answering service that will direct you to the physician on call. he or she can then guide you on what to do.
If you need to cancel or reschedule an appointment, particularly a well visit or consultation, please do so at least 24 hours in advance. A significant amount of time is allotted for these appointments and we would like to offer this time to other patients if you are unable to keep your appointment. There is a $35 fee for routine appointments missed or cancelled with less than 24 hours notice.
Forms and Prescription Refills
We ask at least 72 hours notice for prescription refills so that we can review your child’s chart and ensure we are offering the best care for any ongoing problem. If you need your refills more urgently, please indicate this to your child’s physician.
School, daycare, camp and similar forms take time to review, and to provide all requested information. We routinely complete these forms in two weeks. If you require the forms to be filled out on a more urgent basis, please indicate so. When giving us the forms, please make sure you fill out your part on the form. Also, please let us know how you would like us to deliver the forms back to you. We can mail to you, fax it, put it in the patient portal, or you can come pick it up when ready.
Record Release Fees
- The Health Information Portability and Accountability Act (HIPAA) restricts us from releasing medical information without your written permission. Medical records will be provided to you electronically (through the patient portal) at no cost.
- A fee of $0.76 per page will be assessed for printed records, up to a maximum of $22.00 per record.
- Please allow at least 2 weeks to process medical records.