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Cancellation Policy

Patients must call 24 hours in advance if they are unable to keep their scheduled appointment.  If the appointment is not canceled in advance, the patient will be charged a $35 No Show charge.

Medical Records

The Pediatric Clinic requires an authorization form to be filled out on each patient for the release of each child’s medical records.
In addition, there is a fee of $5.00 for the first 5 pages and .25 per page thereafter and is due when records are copied for the patient.

Notice of Patients Privacy Rights

Effective Date of this notice: March 28, 2019

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

You have the right to:

  • Get an electronic or paper copy of your medical record
  • Ask us to correct your medical record
  • Request confidential communications
  • Ask us to limit what we use or share
  • Get a list of those with whom we’ve shared information
  • Get a copy of this privacy notice
  • Choose someone to act for you
  • File a complaint if you feel your rights are violated
Your Choices

You have some choices in the way that we use and share information as we:

  • Tell family and friends about your condition
  • Provide disaster relief
  • Include you in a hospital directory
  • Provide mental health care
  • Market our services and sell your information
  • Raise funds
Our Uses and Disclosures

We may use and share your information as we:

  • Treat you
  • Run our organization
  • Bill for your services
  • Help with public health and safety issues
  • Do research
  • Comply with the law
  • Respond to organ and tissue donation requests
  • Work with a medical examiner or funeral director
  • Address workers compensation, law enforcement, and other government requests
  • Respond to lawsuits and legal actions
Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record. You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record. You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications. You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.

Ask us to limit what we use or share. You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information. You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated. You can complain if you feel we have violated your rights by calling our clinic and speaking with the privacy officer. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

  • Marketing purposes, Sale of your information, and most sharing of psychotherapy notes
Our Uses and Disclosures

We typically use or share your health information in the following ways.

Treatment. We can use your health information and share it with other professionals who are treating you. A doctor treating you for an injury asks another doctor about your overall health condition.

Payment. We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.

Operations. We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:

Public Health. We can share health information about you for certain situations such as:
Preventing disease, Helping with product recalls, Reporting adverse reactions to medications, Reporting suspected abuse, neglect, or domestic violence, and Preventing or reducing a serious threat to anyone’s health or safety

Research. We can use or share your information for health research.

Comply with the law. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Organ and tissue donation requests. We can share health information about you with organ procurement organizations.

Medical examiner or funeral director. We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Worker’s compensation, law enforcement, and other government requests. We can use or share health information about you for workers’ compensation claims, law enforcement purposes or with a law enforcement official, with health oversight agencies for activities authorized by law, or special government functions such as military, national security, and presidential protective services.

Lawsuits and legal actions. We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see:

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Click Here to download a copy of the Notice of Privacy Practices

Financial Policy

Thank you for choosing The Pediatric Clinic as your health care provider. We are committed to providing you with the best possible care. Your clear understanding of our Financial Policy is important to our professional relationship. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment. Please ask if you have any questions about our fees, financial policy, or your responsibility.

  • All patients must complete our patient information form before seeing a physician or nurse practitioner.
  • Payment is due at time of service unless prior arrangements have been made with our financial department.
  • We accept cash, checks, Visa, MasterCard or Discover.

Insurance Coverage

Your insurance coverage is a contract between you and your insurance company. We are not a party to that contract. If you have insurance, we will help you receive maximum benefits. If we accept your insurance, you must pay any co-payments and/or deductibles allowed at the time of service.

  • In the event we accept assignment of benefits, the patient is still ultimately responsible for all charges. If your insurance company has not paid your account in full within 45 days, the balance is due in full from the patient and/or guarantor.

Usual and Customary Rates

Our practice is committed to providing the best treatment for patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. We file claims as a courtesy to our patients. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, etc., other than to provide factual information as necessary. You are responsible for the timely payment of your account.

Untimely Payments

In the event of untimely payments, an outside collection agency may and will be utilized to secure payment on all past due accounts.

Insurance Referrals

In the event the patients’ insurance company requires referrals to other physicians or outside tests, your Primary Care Physician must approve those referrals. Please call at least two (2) days in advance of the appointment with another physician because your doctor may need to evaluate the need of your request with an office visit and some insurance companies request at least 2 days to complete a referral.

Assignment of Insurance Benefits

I request that payment of authorized Medicaid and/or other applicable insurance benefits be made on my behalf to The Pediatric Clinic for any services furnished to me by The Pediatric Clinic. By signing below, I authorize any holder and its agents to release my medical and/or other necessary information, which may be needed to determine benefits payable for the Healthcare Financing Administration and/or its agents.

Authorization to Release Information

I hereby authorize The Pediatric Clinic to furnish any medical records and information necessary to other caregiver offices regarding my child’s illness and treatment.

No Show Policy

I hereby acknowledge The Pediatric Clinic, P.A. charges each patient a set fee of $35.00 every time a scheduled appointment(s) is not canceled 24 hours prior to the appointment.


I understand it is my responsibility to insure that my newborn is promptly added to medical insurance. If my newborn does not have medical insurance by their next visit, I will be responsible for the full balance in full on the date of service and all others following until medical insurance coverage is provided to The Pediatric Clinic.

Vaccine Policy Statement

  • We firmly believe in the effectiveness of vaccines to prevent serious illness and to save lives.
  • We firmly believe in the safety of our vaccines.
  • We firmly believe that all children and young adults should receive all the recommended vaccines according to the schedule published by the Centers for Disease Control and Prevention and the American Academy of Pediatrics.
  • We firmly believe, based on all available literature, evidence, and current studies, that vaccines and the preservatives in them do not cause autism or other developmental disabilities.
  • We firmly believe that vaccinating children and young adults may be the single most important health-promoting intervention we perform as healthcare providers and that you can perform as their parent/caregiver.
  • Unfortunately, because vaccines have been so effective, some people are starting to believe they are not needed. However, decreased vaccination rates can lead to the resurgence of serious illnesses.
  • Vaccination is important not only for your own child's health, but for others as well. It helps protect those who cannot be vaccinated.
  • We realize that misinformation can cause fear regarding vaccines. We urge you to discuss any concerns with your child's healthcare provider.
  • If you are unwilling to vaccinate according to the recommended schedule, we will ask you to find another healthcare provider who shares your views.

Thank you for reading our policy. We always strive to do what is best for our patients to keep them healthy and safe, which is why we firmly recommend vaccinations.

Click Here to download a copy of the Pediatric Clinic Vaccine Policy Statement