Please correct the errors described below.

We reserve our right to discharge a patient from our clinic for any of the following:

  • Non-payment of an account balance
  • Abusive language or behavior directed toward staff, use of profanity
  • Disruptive behavior that upsets other patients in the clinic
  • Destructive behavior that damages clinic property or stealing clinic property
  • Missing 2 or more appointments without 24 hours notification
  • Blatant disregard of an advised plan of care
  • Misuse or the suspicion of misuse of prescription medications
  • Request to commit insurance fraud, forging clinic documents
  • Habitual verbalization of dissatisfaction with our policies

Facts about HIPAA

The Health Information Portability & Accountability Act (HIPAA) is a group of FEDERAL regulations that all physician offices, hospitals, providers, etc. are required to meet after April 14, 2003. HIPAA requires us to provide copies of our Notice of Privacy Practices to each person/family seen at our office after April 14, 2003. Please refer to the Notice of Privacy Practices for detailed information about requirements and your rights to privacy.

HIPAA requires the completion of certain paperwork, including your signature that you have received a copy of the Notice of Privacy Practices.

HIPAA restricts the use and release of your medical information without a signed authorization.

HIPAA requires that authorization forms are completed & signed before any information can be released to third parties (schools, daycares, etc.) Therefore, we
cannot fax or send school excuses, school/daycare forms or medication instructions to schools or daycares without a signed authorization form.

We may fax or mail information to the parent/guardian home or work. The parent/guardian would then be responsible for forwarding the information to the appropriate school or daycare.

HIPAA requires that any use or release of medical information only contain the minimum amount of information necessary for the required function.

HIPAA requires that we restrict access to patient areas of our office. Therefore, we request that you remain in the exam rooms, and that you check with our front office staff before entering any patient area. Photography and video recording is not permitted while in our office.


In order to assure that our practice is in compliance with HIPAA Privacy Regulations, Pediatric Health & Wellness does not transmit patient information via email or text message. Texting is not considered a secure method of transmitting private health information. Some carriers may store the text messages for a time, meaning they could be read by someone else. Not everyone protects their phone in the event of loss or theft, leaving private health information potentially unprotected.

Email is easier to falsify than handwritten or signed hard copies. In addition, it is impossible to verify the true identity of the sender, or to ensure that only the recipient can read the email once it has been sent. Email can be forwarded, intercepted, circulated, stored or even changed without the knowledge or permission of the physician or the patient. Email senders can easily misaddress an email, resulting in it being sent to many unintended and unknown recipients. We apologize for any inconvenience you may feel this causes.

Please sign below that you understand our policies.

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.

Your information will be encrypted.