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I understand the above information & guarantee this form was completed correctly to the best of my knowledge & understand it is my responsibility to inform this office of any changes in my child’s medical status.
I understand it is my responsibility to bring my child’s current insurance card to each visit.
I understand that I am financially responsible for copay, deductible, estimated coinsurance at the time of service and all charges not covered by insurance. I authorize the release of any medical information required to process claims. I also authorize payment of medical benefits payable to Practical Pediatrics, Dr. Michael W. McCoy.
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.
Office Hours
Monday - Thursday 8:00am - 12:30pm & 2:00pm - 5:00pm
Friday 8:30am – 12:30
Telephone Hours
Monday - Thursday 8:00am - 12:30pm & 2:00pm – 5:00pm
A nurse is available during regular business hours to answer any questions and give advice. Nurse calls are returned in the order they are left and by the nature of the call. All calls left before 4:30 will be returned the same day. In case of emergency please dial 911. For after hour emergencies please call the main number for further instructions.
When calling for a refill on an existing prescription, please contact your pharmacy and they will contact our office. Controlled prescriptions must be requested 24 hours in advance. As of April 2021, all controlled prescriptions will be sent electronically, please make sure the correct pharmacy information is provided. Our office is unable to resend a controlled substance to a different pharmacy on the same day. All medication forms for school/daycare there will be a $5.00 fee to complete.
Nurse visits, such as weight checks, and immunization updates must have scheduled appointments. It is recommended to make all Well Child appointments 2 months prior to needing appointment. School physicals are scheduled in the summer months and are filled quickly, please call ahead. If you are unable to keep your appointment, please call our office 24 hours prior to appointment time. Failure to cancel a Well Child and/or ADHD follow up appointment will result in a $25.00 missed appointment fee. Failure to cancel a Consult or ADHD Evaluation will result in a $50.00 missed appointment fee. If you are late for your appointment (>15 minutes) we will do our best to accommodate you. However, it may be necessary to reschedule your appointment.
Our office will complete any school physical forms at the time of appointment. A request for forms to be completed other than at your appointment requires a 24-hour turn around and a fee of $10 per form payable upon request. A copy of your child’s shot record will be given at each Well Exam. If an additional copy is needed, there will be a $5.00 fee for each request. Family and Leave Act forms are $10.00. All forms that require a physician signature only there will be $5.00 fee per form. Patient portion of the forms must be completed by the parent/ patient before the physician can complete his/her portion.
All patients must bring a valid insurance card and be prepared to pay all patient portions (co-pay, deductibles) at the time of service. If your plan requires a deductible to be met, we will collect an estimated amount at each appointment and a statement will be mailed for any remaining balance due. If our office is unable to verify coverage for your child, please be aware you will be responsible for the full payment at the time of service. It is your responsibility to notify the office staff of any changes in your insurance, address and/or phone numbers. Our office will file your primary insurance only for you, we do not accept secondary insurance. If payment is not received by your insurance within 45 days, it will become your responsibility to pay the outstanding balance. We charge a $30.00 fee for all returned checks. Payment of all returned checks and all future payments will need to be paid by cash or credit card.
I understand that I am financially responsible for all charges, whether or not they are covered by my insurance. I authorize the release of any medical information required to process claims. I also authorize payment of medical benefits to the provider of benefits. I understand this office does not accept Medicaid or the fee for Medicaid patients.
Should you require a referral to a specialist, please allow 4 business days for all non-emergent referrals. It is your responsibility to know if your specialist is a participating provider. Referrals must be approved by the provider before they are issued.
If you want a copy of your child’s records, or want us to send your child’s records to a different provider, please request and complete our Authorization to Release Medical Records Form. There is a $25.00 fee per patient for medical records that must be paid upon request. Please note the balance on the account must be paid before records will be transferred.
We provide records of your child’s visits rendered here at Practical Pediatrics and consultations from specialist while under our care. For any other medical records you will need to request them directly from your previous provider(s).
I have read the above information and understand the policies and procedures of Practical Pediatrics.
I acknowledge that I have been given a copy of Practical Pediatrics’ Notice of Privacy Practices, version effective 09/23/2014. I consent to the uses and disclosures of my health information as outlined in the Notice. I have been afforded the opportunity to read and ask questions.
For Practical Pediatrics’ use only:
I am the parent or legal representative of the above-named minor child. I hereby consent to the medical and surgical examination, diagnosis and treatment of my child by Dr. Michael McCoy and the health care professionals at Practical Pediatrics, as deemed necessary by them in their professional judgment. It is understood that the practice of medicine is not an exact science, and no guarantee can be given by anyone as to the results that will be attained from any diagnosis or treatment.
The following individuals are authorized to view, discuss and/or obtain my child’s health care information. The following individuals may also seek medical care and make decisions in relation to advice rendered by Practical Pediatrics.
Add Family or Representative of Minors
For Patients 18 years and older, I authorized the following adult(s) to receive information regarding my medical information:
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Please write in the phone number(s), if you would like a staff member to leave a message.
to release the following information for :
The Information specified below may be release to:
SPECIFIC INFORMATION TO BE RELEASED: (please check all that you are requesting to be released)
I understand that is a $25 fee, per child for medical records. I also understand fees for copies are due and payable before copies are released.
I understand this authorization expires 180 days from the date signed.
I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations.
I understand that photocopy or facsimile of this authorization is a valid as the original.
I understand that I may revoke this authorization at any time by notifying this office in writing and that such revocation will be not have any actions taken by this office before this revocation.
Please list all those living in the child’s home.
Add Sibling
Have any family members had the following!
Does your child have, or previously had
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