Forms & Policies
- Medical Release Form [pdf]
- Food Allergy Action Plan [pdf]
- Practice Immunization Policy 1/2009 [pdf]
- Patient-Centered Medical Home Brochure 4/2013 [pdf]
Laboratory Testing & Your Insurance 8/14/2012
Lab tests, x-rays, & other testing ordered by your physician may or may not be covered. Coverage may vary based on individual insurance plans or diagnosis. Deductibles and/or co-insurance may apply to your testing (even when ordered by your primary care physician or specialist). All tests requested by third party sources (school, daycare, work, court, other insurers, military, etc.) will not be covered by your insurer. You will be responsible for payment. Coverage will vary.Please check your subscriber certificate or consult with your insurance carrier directly to inquire about coverage details.
Relationship to Patients 4/15/2010
In an effort to ensure an accurate family history in our patients' accounts, we will be asking those accompanying our patients to the office to identify themselves clearly as mom/dad, stepmom/dad, or whichever relationship applies.
When bringing a child or adolescent into our office, our check-in staff and medical assistants will be asking your relationship to the patient. This will apply when calling our office as well.
We want to be sure to secure our patients privacy rights and not release any information to anyone but a parent or guardian. Thank you for your understanding and please do not hesitate to call us with any questions.
Demographic Information & E-Mail Addresses 7/14/2009
Upon checking in for an appointment, our staff continues to verify all demographic information. We are asking for e-mail address to be provided for the use of physical reminder notices. These notices will be sent via email, or standard mail if necessary, three months prior to the physical due date.
Please be sure you keep your contact information up to date. If you have changes, you may email them to firstname.lastname@example.org or call the office. Please be sure to include patient’s name & date of birth.
Traveling & Long Distance Calls 5/28/2008
Please be aware that if you are traveling out of the country we are happy to assist you during normal business hours. Although we are limited in the services we can provide, especially when you are out of the country, we are available for questions. Also, be aware that for any calls that need to be returned out of area, you will be held financially responsible.