Forms & Policies

Patient Forms

Get your child’s first appointment started off quickly and easily by downloading and filling out our patients forms before you come in. Simply click on the links below, fill out on your computer in advance and then print on white paper (or print and fill out legibly in pen), provide the requested information, and bring the forms with you when you check in. You’ll save yourself time and the hassle of trying to fill them out in the waiting room.

New Patient Forms

  Download Forms

Formularios de Admisión de Pacientes

  Descargar los Formularios

ADHD Packet

  Download Forms

Records Release

  Download Forms

Privacy Policy

  View Privacy Policy

To view our forms, you may need Adobe Reader. You may download Adobe Reader for free by visiting adobe.com.

Financial Policies: Insurance and Billing Practices

Thank you for choosing The Pediatric Center to care for the needs of your child(ren). We are committed to providing your child with the best possible medical care. We never want costs to stand in the way of quality treatment, which is why we are dedicated to providing our patients with care that is both effective and affordable. For your convenience, we accept cash, checks and Visa, MasterCard, American Express and Discover credit cards. If you have special financial needs, we are willing to work with you. The following information is provided to avoid any misunderstanding or disagreement concerning payment for professional services.

We will file insurance as a COURTESY; however, YOU ARE ULTIMATELY RESPONSIBLE FOR YOUR CHILD’S CHARGES.

Our office is committed to helping you maximize your insurance benefits. We are preferred providers for most commercial insurance companies. When you visit our office, bring your current insurance card with you. If you change insurance companies or if you have a change of address, telephone number(s), or employer, please notify the receptionist and we will update your information. If an insurance referral is necessary, please bring the completed form with you to your appointment. We will fully attempt to help you receive full insurance benefits; however, you are personally responsible for your account.

General Guidelines and responsibilities:

  • Bring your current insurance card with you
  • If your insurance denies our charges, or does not pay us in a timely manner, you will be billed for the entire balance. You will be expected to pay your balance in full within 60 days or call our billing office to make payment arrangements. If you do not pay in a timely manner, your account may be referred to a collection agency and reported to the credit bureau.
  • Pay your co-payment and/or any deductibles at each visit. Payment can be made by cash, check or accepted credit cards. It is NOT our policy to bill for co-payments. If you have no insurance, payment for an office visit is to be paid at the time of service. A prompt pay discount is available if the visit is paid in full on the day of the appointment. If you have insurance and elect to pay in full with a discount, we will NOT bill your insurance.
  • If your child has insurance that we do not participate with, or your child does not have insurance, payment in full is expected at the time of service. Your child will be a “Private Pay” patient in our office. We offer a prompt payment discount to “Private Pay” patients if the charges are paid in full at the time of service. Please see one of our front desk employees or billing specialists if you have any questions.
  • If your insurance plan is with Medicaid, their policies may require you to choose our clinic as a Primary Care Provider as part of their Healthy Connections Plan.
  • Secondary Insurance: We will file secondary insurance if it is applicable, as long as we have the appropriate information from you on file.
  • Some medical procedures may not be covered by your insurance plan. You will be responsible for payment in full of these charges. For example, if your insurance plan is Medicaid, Circumcisions of newborn males will not be paid by insurance and you will be required to pay the appropriate fee before the procedure is performed.
  • If you have questions about your insurance, we are happy to help. However, specific coverage issues should be directed to your insurance company member services department. The telephone number is usually located on your insurance card.
  • If you fail to make payment in full for services that are rendered to you, your outstanding balance will be sent to an outside collection agency. You will be responsible for any fees associated with the collection of your outstanding balance.
  • In cases of divorce and/or separation,  it will be the guarantors’ responsibility to pay any balance originating from that visit. It is the guarantors’ responsibility to work out the details of a divorce decree…not The Pediatric Center’s. The Pediatric Center will not participate in disputes between custodial and noncustodial parents. Ultimately, the guarantor listed on the account will be responsible for payment of services.
  • If a sibling is added to an appointment, they will have a separate charge and Copayment collected if required by insurance.
  • We will charge your account a $25 non-sufficient funds charge if your check is returned to us for insufficient funds.
  • Should your account remain outstanding more than 90 days, a final letter or other communication will be issued. Balances not paid in full within the 10 days of the date on the final request letter, text or other communication may be forwarded to a collection agency.
  • We may present charges to you by written statement via the mail, email, phone call, text message or any other possible method of communication.  If we do this, we expect that each charge will be paid in full by utilizing our convenient options available for payment. You may pay by phone using accepted credit cards or you may mail a check for the full amount due the first time it is presented to you. We may send you statements and reminders of charges made and amounts that we believe must be paid, or may call you about the same.

If at any time you have questions or problems with our fees or payment process, please don’t hesitate to call our billing office at 208-523-6212.

We must emphasize that as pediatric providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are strictly your responsibility from the DATE SERVICES ARE RENDERED.

Please note: physicians follow accepted national guidelines when determining your charges. They must code based upon what services were provided and cannot take into account particular health plan benefits.

Appointment Cancellation & No Show Policy

We understand that unplanned issues can come up and you may need to cancel an appointment. If that happens, we respectfully ask for scheduled appointments to be cancelled at least 2 hours in advance.

Our providers want to be available for the needs of all of our patients. When a patient does not show for a scheduled appointment, another patient loses an opportunity to be seen.

If a missed appointment occurs, we understand life happens and will notify you of our no show policy. If there is a second missed appointment, there will be a block placed on your account and a $15.00 reinstatement fee, per child, may apply. The block will prevent any future appointments to be scheduled. A third missed appointment will result in the reinstatement fee doubling to $30, a fourth missed appointment $45.00 and so on. Any reinstatement fee will need to be paid in full prior to any additional appointments being scheduled. This policy applies to the entire family, not just an individual child.

Thank you for being our valued patient. We also appreciate your understanding and cooperation as we institute our policy. This policy will enable us to open otherwise unused appointments to better provide care to our patients.