Policies and Guidelines Agreement

Pediatric Health Center of Conyers

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PEDIATRIC HEALTH CARE POLICIES AND GUIDELINES AGREEMENT

Welcome

We are glad that you have decided to become a part of our Pediatric Health Care of Conyers. Our goal is to provide you with excellent healthcare in a friendly and compassionate environment. Please take a moment to become familiar with our office’s policies and guidelines, then sign the acknowledgement at the bottom of this page and return it to our office. Our treatment relationship is a partnership and we look forward to helping you achieve the best health outcomes possible. If you need assistance completing the forms, please see our Patient Coordinator. You may contact our Practice Administrator Sheldon Stewart (sheldon@pediatrichcenter.com) with any issues you may have concerning our staff or Insurance questions.

First time Visit

Please arrive at least 10 – 15 minutes prior to your appointment time. A nurse will go over your past medical history. Please bring all of your medications in their original containers. If you have co-pay or have not yet met your deductible, please be prepared to pay it when you check in at the front desk. If you do not have insurance coverage, payment will be collected after you see the doctor. Payment is due at the time of service.

Follow-Up Visits

Please arrive 5 – 10 minutes before your schedule appointment time. It is our goal for you to be ready to see your physician on time. Notify us if you have any changes in your insurance or contact information. Please make us aware of any significant updates in your medical history, such as hospital or urgent care visits, and any changes in your medications by another healthcare provider.

Follow-Up Care

Your treatment plan may involve follow-up care. As such, we may schedule you for diagnostic tests, follow-up appointments with us or other providers. If you do not keep the appointment, it is important that you contact us to discuss alternatives. Likewise, if you decide to seek care from another provider, please let us know. It is our policy to inform you of test results, however, if you have not received your test results within the expected time, please contact our office. Some patients may make an appointment for a mammography exam and receive the follow-up report without a doctor's referral. This is known as "self-referral.” In these cases, we may not be aware of your test results. Please provide us with a copy of your test results and make us aware of any recommendations for follow-up care.

Late Arrivals

We all run late sometimes. In the event that you are late for your appointment, we will try our best to work you back in to the schedule. Depending on how busy we are, you may be required to reschedule your appointment. If you are more than 10 minutes late, you may be asked to reschedule.

Appointment Cancellations

We understand that sometimes plans change. We ask that you reschedule appointments at least 24 hours in advance so that we may give that time to someone else. Although unexpected events may necessitate missing an appointment, if you miss 2 appointments without following the cancellation protocol then you will be charged $40.00. If you miss 3 appointments without following the cancellation protocol, you may be dismissed from the practice. You will receive a written notification if you miss 2 appointments. If you miss your first appointment, you may be prohibited from rescheduling.

Sick Visits

Established patients who need acute care should call as early in the day as possible so that we can accommodate you. Patients are seen by appointment only. Depending on the availability of your physician, you may be asked to see another provider.

Medication Refills

For non-emergency, and routine medication refills, please allow 48 hours and ask your pharmacy to send us a refill request. Also, please let a nurse or physician know if you need a 90 day prescription. Narcotic medications will only be written for a 30 day supply at a time. Additional refills to the original prescription will be at the doctor’s discretion. Early refills will not be given. You may be requested to contact your pharmacy to ask them to fax a refill request to our office to assure that exact fill dates are documented accurately. You may also be asked for a follow-up appointment for certain refill requests.

After Clinic Hours and Weekends

You may reach the on-call physician by calling 770-483-4431 and following the instructions as given. Please remember that your appointment is to focus on your medical needs. If your family member, who is also our patient, has any medical needs (including medication refills), we will be happy to schedule an appointment for them at the conclusion of your office visit.

Audio or Video Recording

In the interest of your privacy, as well as that of our workforce, unauthorized audio or video recording by patients, family members, and/or visitors is strictly prohibited. Personal devices with an audio and/or video recording function should not be used or be visible in the office and must be stored accordingly. To the extent a member of our workforce is aware of any unauthorized attempt to photograph or record a patient and/or workforce member, the workforce member will take reasonable steps to ensure that patients and/or workforce members are not photographed within the office. We respectfully request that you turn off or silence your cell phone during your office visit.

Parents Living Apart

The parents shall communicate with each other about the children, and shall use good faith efforts in their attempts to resolve differences of opinion regarding any major decision concerning the children with primary emphasis being on arriving at a solution which will be in the best interest of the children. Pediatric Health Care will not be in any position to act as an intermediary between the parents. On matters of billing and financial responsibility, accounts of minor children of separated or divorced parents are the responsibility of the parent who consents to the treatment.

Chaperones

Our practice is committed to providing a safe and comfortable environment for all patients. We provide formal chaperones for all intimate exams, however you have a right to have a formal chaperone present for any examination, procedure, or treatment. Please notify a staff member is you want a chaperone.

Vaccine Policy

One of the best ways to keep your children healthy is to make sure they are up-to-date on their vaccines. At our practice, we do not accept patients who do not receive their recommended vaccines on the recommended schedule (unless there is a medical contraindication diagnosed by one of our physicians.) This is for the safety of your children, and the safety of our other patients, their families, and our staff.

Unsolicited Text Messages:

Please refrain from sending unsolicited text message to our providers and staff. You may use our secure portal to communicate with our staff.

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