General Fees for Pediatric and Adolescent Medicine

1. We collect copayments and balances due for all visits when you check-in, and this is based on the contractual agreement between you and your insurance health plan. We accept cash, checks, Visa, MasterCard, and Discover Card.

2. When appointments are missed, or canceled with little notice, it leaves an opening that could have been used for another patient. We reserve the option to charge $30.00 (or the amount of your copay) for NO-SHOWS for all types of visits. This fee is not covered by your insurance.

3. The following services are provided to you at no charge:

• Preschool and Kindergarten entrance forms
• Computer-generated immunization records
• Regional Center records requests
• Transferring medical records to another physician (one time only)
• Parents’ request(s) for 1-2 pages from the chart
• Completion of Camp and Sports Physical forms (if requested within two weeks of the physical exam.)

4. We charge for the following services that are not covered by your insurance:

• Repeated requests for transfer of medical records from doctor to doctor as well as copies of records sent to parent(s) for personal use-$25 flat rate for a multi-page PDF, CDR or full records printed due to outdated technology. Paper copies can be requested for an additional $0.25 per page.
• Completion of the following forms (if the form is presented to the office later than two weeks after the Physical Exam): Camp Physicals, Sports Physicals, College Entrance Physicals/Proof of Immunization and/or TB status, and other Miscellaneous Documents-$25
• Medication administration form for school or camp (1 page, only)-$20
• Completion of FMLA, IHSS, other government forms, and School Mandated Concussion forms-$30
• Returned check charge-$30 per check

If you have any questions about our fees or payment policies, please feel free to speak with our Office Manager, Lorraine Tiffany Malone, M.S.