Office Forms & Insurance Billing2018-12-05T21:31:12+00:00

Project Description

2019 New Patient Forms
These forms are needed for your first visit to Pediatric Wizards. Please fill them out prior to your first visit. Also, make sure to print out the patient information form found under the Patient Information Tab. If you are transferring from another practice, please click on and print out the medical records release form. Kindly fill it out and send it to their office so we may have your child’s records prior to their first visit.

2019 Established Patient Registration
Print these, fill them out and bring them in on your first visit of the year.

M-Chat – (18 & 24 months)
Please fill these forms out prior to your child’s 18 month & 2 year well visit in our office.

30 Month Questionairre – (30 months)

Newborn Feeding Questionnaire – 1 week visit
A questionnaire used to determine if you are experiencing feeding issues with a newborn or infant. Please fill this 24 hours prior to your 1 week follow-up visit in our office.

Medical Records Release Request
To request a copy of your child(ren)’s medical record, please fill out the following form and fax/mail to our office. Medical Records may take up to 14 business days to process once the signed request is received in our office.

Designee Authorization Form
If someone else needs to bring in your child for a visit, please have this form filled out and with them.

Anxiety Screening Forms

PHQ Anxiety and Depression Form

Crafft Drug & Alcohol Form

ADHD Parent Evaluation and Follow Up Forms

Conners Parent Form
These forms include parent evaulation and follow up forms for ADHD assesments and medication monitoring.

HIPAA 
Notice of Privacy Practices. This is for your records only. You do NOT need to print this for our office.

New Patient Vaccination Policy

Pediatric Medical Records Request

Medical records will be released within 14 business days of receipt of a signed written request. As a professional courtesy, we will release records from one provider to another at no charge, on one occasion only.  All outstanding balances on the patient’s account must be paid in full prior to the release of records.  Medical records will not be mailed, other than to other medical providers. Parents requesting additional records for themselves will be charged $1.00 per page for the first 25 and $0.25 per each additional page.

Parents/Patients requesting shot records and physical (blue and yellow) forms will receive one copy of each for free per well child visit.  If additional forms are requested, there will be a charge of $25.00 per form.  We appreciate your understanding since the completion of these forms is very time consuming for our staff.

Any records needed for attorneys must be requested by the attorney with a signed request.  If the records are not requested by the attorney, we will assume they are for the patient and record charges will apply as described above.  The records will not be released to the attorney until payment of the invoice for records has been received by our office, as record charges will apply.

Please download and complete the medical records release form and return it to our office.

Billing Policy
When visiting our office, please bring your most current insurance card to ensure the information is valid at the time of service.  Incorrect or out-of-date information will delay your claim and you may be held responsible to full payment of the claim.

The insurance companies do not supply us with claim forms or policy numbers.  If your insurance company requires specific forms, it is your responsibility to provide our office with the same.  We must emphasize we cannot accept responsibility for collecting or negotiating insurance claims.  We will gladly assist in completion of required additional forms and supplying additional information and/or patient records.

Payment Policy
Payment is due at time of service and is collected at check-in.  This includes co-pay, co-insurance, deductible, and/or any outstanding balance on the account.  As a reminder, billing a health insurance provider on your behalf is a courtesy we provide to our patients.  Payment may be made with cash, check, MasterCard, Visa, Discover & Amex.  Co-payment is determined from your insurance card, which you must bring with you to each visit.  There will be a $25 charge for all returned checks and we will no longer accept checks as payment for future visits.

For all services rendered to minors, the adult accompanying the patient is responsible for payment, whether a parent/legal guardian or not.  If your child will be brought to the appointment by someone other than his guardian, be sure he or she is aware of this policy.

Click here to make a payment through our Patient Portal.

 Form Charge Policy – (click me)