Office Procedures and Policies

I give any doctor at Valencia Pediatric Associates permission to obtain lab, x-ray, or immunization information from any source for my child.

Financial Policy

Our relationship is with YOU, not your insurance company. Know your benefits. Inform us of changes and bring your new card in. We cannot bill without a valid card. If your insurance has lapsed and you do not give us your new information, you will be responsible for the bill. We encourage you to contact your insurance company to inquire about your benefits. Know, for example, if your insurance does not pay for check-ups which are less than 12 months apart. Know which labs, immunizations, and which hospitals are covered.

• Valencia Pediatric Associates requires a credit or debit card be kept on file for all its patients.
• Insurance companies require copays, coinsurance and deductibles to be collected at the time of service. We are not allowed to waive them or bill for them.
• If a claim is denied, it is your responsibility to contact the insurance company and, if not paid, it is also your responsibility to pay it.
• Additional issues addressed at well check appointments may be billed separately. Some insurance companies will not cover two office services on the same date so payment for one of them may be denied by the insurance company or an additional co-payment may be required.
• If after drawing up a vaccine a parent/patient declines to have it administered, the cost for that vaccine will be patient responsibility.
• If parents are divorced, whoever brings the child into the office is responsible for co-pays and for having a current insurance card.
• School forms, letters, and copies of records are charged depending on the extent of work they entail.
• I authorized and voluntarily consent to the participation and treatment of my child in a Telemedicine Consultation and or/ treatment with Valencia Pediatric Associates.
• Physicals/ Well Check appointments must be cancelled within 24 hours or you will be charged a$75 fee.
• Med Check appointments must be cancelled within 24 hours or you will be charged $55 fee. Acute/ Sick Appointments must be cancelled 30 minutes prior to scheduled appointment time or you will be charged a $40 fee.
• New patient well check appointments must be cancelled within 24 hours or you will be charged$100.
• All appointments not cancelled or missed, fees apply.
• Returned checks incur a fee of $35.
• I authorize the release of any information acquired in the course of treatment necessary to complete and file medical claims to my insurance company on my behalf.
• I hereby acknowledge financial responsibility for costs of services rendered for me or for the person whose account I am acting as guarantor.
• I agree to receive text messages from Valencia Pediatrics Associates for the purpose of communication with staff/ doctors. (There's no guarantee you will receive text messages.)

Acknowledgement of “Abuse Free Zone”

At Valencia Pediatric Associates we appreciate and respect our staff. It is our belief that our staff should have a work environment free from verbal and physical abuse. We expect each one of you to treat each one of our staff members as you would like to be treated. Outbursts against our staff will not be tolerated and may result in your discharge from the practice.

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