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Office Policy Form


All Patients:

- Patients are seen by appointment only.

- All patients who are 15 minutes late or later may be asked to reschedule their appointments so that we do not keep other scheduled patients waiting.

- Payment is due when services are rendered unless prior arrangements have been made.

- Newborn Insurance or Medicaid patients have 30 days to add newborn to Insurance or Medicaid coverage.

- Antibiotics are not prescribed or refilled without a physician assessment.

- Referrals and authorizations are not given without a physician assessment.

- There will be a $30 return check fee on all returned checks.

Telephone Calls:

- The office encourages parents to use common sense and educational resources before making telephone calls to this office especially after hours. Excessive telephone calls may become subject to charge. However, do not hesitate to call for a true emergency.

Insurance Patient Only:

- A copy of your Insurance card will be required for initial visit. Thereafter, you MUST bring child's current insurance card (if applicable).

Medicaid Patients Only:

- A newborn is covered under the mother's current Medicaid eligibility form for the first 30 days after birth. A copy of this form is required in order for this office to file the claim. Thereafter, you MUST bring the child's current Medicaid eligibility form each visit in order for the child to be seen.

I understand the above policies and agree to abide by them.


Parent/Guardian Signature                                                                    Date

Release and Assignment

I authorize Adult & Pediatric Physicians Group physicians and members to release and furnish on a confidential and strict need to know basis all medical and financial data related to care of the above named patient that is necessary to facilitate payment by third parties for services rendered by physician, or to assist with, or aid in medical outcomes evaluation purposes. Such information may be released to insurance companies, HMOs and PPOs, IPAs, Medicaid, or other governmental or third party payers, or any organizations contracting with any of the above entities to perform such functions.

I authorize the personnel of Adult & Pediatric Physicians Group to render medical or surgical treatment to my dependent child now and anytime the child seeks medical attention, even in my absence.

I further authorize and request my insurance company to pay directly to the above named entity the amount due for treatment/services to the patient named below. I understand that all fees incurred in the treatment of this patient by Adult & Pediatric Physicians Group physicians and members are ultimately my responsibility.


Patient's Name                   Parent/Guardian Signature              Relations to Child               Date


Witness (Adult & Pediatric Physicians Group physicians or members)                              Date