Patient Registration

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MOTHER


FATHER

Insurance Information


As pediatricians, we wish to provide your child with the best care possible. We may order certain routine laboratory tests and routine vaccinations that we feel are necessary for the maintenance of good health but that may not be covered by your insurance contract. You will be expected to pay these services in full. We follow the American Academy of Pediatrics guidelines for child health maintenance and will only order a test if we truly believe that it is necessary for your child's health. I, the parent or guardian of the above child do, hereby authorize Acton Road Pediatrics LLS, and all of its physicians to give to this this child immunizations and treatments that such physicians deem necessary for his/her health.

I authorize the release of medical records on this child to other physicians and insurance providers necessary for my child's care and in compliance with federal HIPAA policies. I acknowledge that I am totally responsible for all the charges for services rendered to this child including non-covered services. If this account is referred to a collection agency or attorney for collection, I agree to pay all costs of collections. A returned check fee of $30 applies to all returned checks.


DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

MEDICAL APPOINTMENT CANCELLATION/NO SHOW POLICY

Thank you for trusting your medical care to Acton Road Pediatrics. When you schedule an appointment with Acton Road Pediatrics we set aside enough time to provide you with the highest quality care. Should you need to cancel or reschedule an appointment please contact our office as soon as possible, and no later than 24 hours prior to your scheduled appointment. This gives us time to schedule other patients who may be waiting for an appointment. Please see our Appointment Cancellation/No Show Policy below:

  • Effective February 1, 2021 any established patient who fails to show or cancels/reschedules an appointment and has not contacted our office with at least 24 hours notice will be considered a No Show and charged a $25.00 fee.
  • Any established patient who fails to show or cancels/reschedules an appointment with no 24 hour notice a second time will be charged a $50.00 fee.
  • If a third No Show or cancellation/reschedule with no 24 hour notice should occur the patient may be dismissed from Acton Road Pediatrics.
  • The fee is charged to the patient, not the insurance company, and is due upon receipt of next statement or visit whichever comes first.
  • As a courtesy, when time allows, we make reminder calls for appointments. If you do not receive a reminder call or message, the above Policy will remain in effect.

We understand there may be times when an unforeseen emergency occurs and you may not be able to keep your scheduled appointment. If you should experience extenuating circumstances please contact our Office Manager, who may be able to waive the No Show fee.

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