Acknowledgment

Patient's Name

Patient's Date of Birth

Parent/Guardian who is filling out the form

I am responsible for any charges at the time of service.

Late/No Show Policy: We strive to follow a strict schedule to avoid wait times. Due to this, if you are more than 1 5 minutes late for any appointment, you will be charged a $25 late fee and have the option to reschedule or be seen in the next available time slot if one is available. If no time slot is available you will need to reschedule.

Failure to provide 24 hours’ notice when canceling said appointments, or not showing up for your appointment will result in a $50 fee being assessed. Please be advised that reminder phone calls are made as a courtesy to you and do not relieve you of the responsibility for remembering your child’s appointment.

We DO NOT bill third party insurance (only your primary insurance), social security or auto accident claims. This is in effect for all patients, regardless of insurance carrier, and everyone is treated equally.

Every insurance plan is contracted differently and we are not always aware of the various levels of coverage. Therefore we are not able to anticipate the final out of pocket costs at the time of your visit, but will do our best on the estimation.

All children must be closely supervised at all times. We want to maintain a clean, well‐kept office. Please do not allow children to climb or mark on walls, chairs, tables, books, etc. Any damage caused by your child(ren) will be billed to you for the replacement costs and/or you may be asked to find another provider for your child(ren).

NO FOOD OR DRINKS are allowed into the clinic to prevent spills and to avoid exposure for children with food allergies (baby formula excluded). Any damages secondary to food or drinks will be billed to family.

There is a $10.00 charge for all triplicate (controlled drug) prescriptions for same day pickup. Our office requires a 48-hour notice when requesting any medication refill. NO refills are approved after hours. You are required to call during office hours to script refill requests. Refills after missed follow-up visits will not be approved.

Referrals: If you participate in an insurance that requires a referral to see a specialist, you must receive that referral BEFORE that visit. No retroactive referrals will be given. We require at least a 1 (one) week notice to arrange that referral.

Lab/Diagnostic Tests/ Specialist Appointments/ Therapy Appointments- You take full responsibility for completing all testing and following up with specialists or therapists as was recommended by your child’s physician.

AUDIO, VIDEO Recordings and PICTURES are STRICTLY PROHIBITED while in the office.

I acknowledge that I have been presented with and have read and understood the Policies & Procedures provided to me by Neighborhood Pediatrics. I agree to abide by the policies of Neighborhood Pediatrics.

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Acknowledgment

Welcome to our office!

Welcome to our office!

Neighborhood Pediatrics