Intake Form

Welcome to Plum Pediatrics!

Here are a few office policies and agreements that we would like for you to be aware of to facilitate a good relationship between you and your pediatrician:

Office Hours: Our office hours are Monday – Thursday 8:00 a.m. to 5:00 p.m. and Friday 8:00 a.m. to 3:00 p.m.

Appointments: Patients are seen by appointment only. Each child needing examination by the doctor should have an individual appointment.

In general, well examinations cannot be scheduled on the day that you call. We reserve only a certain number of well examinations per day. In addition, well examinations cannot be conducted on an ill child. If your child is sick, we will need to reschedule the well examination, but can see your child for his/her illness during the scheduled appointment. This also applies to other conditions that require a significant amount of time for the physician to effectively manage the condition (i.e., asthma, ADHD). We will attempt to contact you 1-2 business days prior to your appointment as a reminder. If we are unable to reach you, it is still your responsibility to keep the appointment. Absences from school will only be excused by our office if your child has been seen in the office for the illness.

Walk Ins and Late Arrivals and No Shows: Rescheduling may be necessary if you are more than 15 minutes late for your appointment. We will try to work you in if time allows. If you cannot keep your appointment, we ask that you cancel 24 hours prior to appointment time. If you “no show” three times we reserve the right to discharge your child(ren) from the practice.

Any appointment missed and not cancelled prior to 24 hours before scheduled appointment time will be assessed a $25 fee to the patient’s account.

Financial Agreement: Fees, Insurance and Health Plans: A Parent/Guardian must notify the office of changes in address, telephone number or insurance. You must bring your insurance cards to every visit. The person who brings the child to the office will be expected to pay at the time of service. You will be responsible for payment of charges from services rendered if we are unable to verify benefits with your insurance company. Insurance companies require collection of your co-pay or contracted percentage of services at every visit. If you have a deductible that has not yet been met, you will be required to pay for the visit in full. If your insurance company does not pay for a service, the charges will be the responsibility of the parent/guardian. We recommend that you always question your insurance company regarding your benefits first if you have any questions about covered services or bills.

WE ARE NOT RESPONSIBLE FOR CHECKING BENEFITS/COVERAGE OF YOUR POLICY. WE ONLY VERIFY ELIGIBILITY.

Plum Pediatrics files primary insurance only for services provided to patients with managed care organizations in which we participate. Co-payments, co-insurance, non-covered services and deductibles are the responsibility of the patient and payable at the time of service. Managed care patients are billed for any remaining patient responsibility after claims have been processed by the insurance company. Proof of insurance is not a guarantee of payment. Patients without insurance or covered under an insurance plan in which we are not contracted are financially responsible for all charges incurred at the time of service. In the event that payment for a service performed is erroneously denied by the insurance carrier, it is the patient’s responsibility to pursue action with the insurance carrier, as the policy is a legal contract between the patient and the insurance carrier. Patients must verify plan participation with our office.

If your child(ren) has insurance that we do not participate with or if your child(ren) does not have insurance we do offer a Private Pay discount.

Below is a list of services that may NOT be covered by your insurance carrier or the charges will be applied to your deductible. This will allow you to make a decision whether or not you choose to receive these services considering you may be financially responsible if it denied by your insurance.

Service	CPT Code
Visual Acuity Screen (Vision Test)	99174
Pure-Tone Hearing Test	92251
30 Month Checkup (recommended by AAP but may not be covered by all insurance plans)	99382 New Patient 99392 Established Patient
Well Checkup over 18 years of age	99385 New Patient 99395 Establish Patient

Balances are due at time of appointment. Financial arrangements will be required for balances greater than 60 days outstanding and prior to appointment.

We accept cash, checks, Visa, MasterCard, and Discover. There is a $25 fee for returned checks.

I request release of payment information to Plum Pediatrics by third party payers when required by coordination of benefits. Furthermore, I irrevocably assign any benefits available to me to Plum Pediatrics and I authorize payment of those benefits directly to that provider.

Medical Records: Medical records can be faxed to another physician’s office free of charge upon release of the medical record. Patient copies of the medical record can be obtained for $25. Copies of the medical record will be provided within 2 business days with a prepayment. Immunization Records are also available on the Patient Portal. We require 72 hours turnaround time for the completion of all forms including, but not limited to daycare admission forms, sports physicals, camp forms, school forms etc. In order for forms to be completed, your child must be up to date on their well child examination. If not up to date we may require a visit in order to complete any necessary forms.

Medication Refills: Patients on medication for ADHD will be seen for medication check-ups every 3 months. Refills for ADHD medications will be provided only if these appointments are kept. Parents/Guardians MUST send a message via patient portal to request a refill for ADHD medications. These prescriptions will be available for pick-up 48 hours after the request has been made during our regular business hours.

Medication refills can be requested on the patient portal to treat stable, chronic medical conditions that require ongoing medication (i.e., asthma, allergies), as long as the patient is established and has been seen for the condition within the past 3-6 months. Refills will not be provided after hours or on the weekends. Please allow 48 business hours for these refills to be completed.

Vaccination Policy: As medical professionals we feel strongly that vaccinating children on schedule with currently available vaccines is absolutely the right thing to do for all children and young adults. If your child has received any vaccinations at any place other than our office, you must provide us with proof of vaccination. If you should absolutely refuse to vaccinate your child despite our efforts, we will ask you to find another healthcare provider who shares your views. Please understand that by refusing to vaccinate your child you are putting your child at an unnecessary risk for life threatening illnesses, disability and even death.

If the parent chooses an alternate vaccine schedule other than the one recommended by our physician, there is a $25 fee each nurse visit.

Patient Portal: Please take advantage of the Patient Portal as we do not have a Nurse Line. All patient messages are answered though our patient portal. Our nurses/medical assistants are always available during business hours to serve your need, however, please keep in mind that our nurses are assisting patients and providers and they will get back to in order of urgency. Please send a message with any questions you may have. All messages received prior to 3:00 p.m. will be returned on that business day; however, depending on the daily schedule, these messages may not be returned until the end of the day, and they will be returned in order of urgency. Messages received after 3:00 p.m. will be returned the next business day.

If you feel your child needs to be seen you should speak with someone in the front office to schedule an appointment, as the schedule fills quickly.

In general, antibiotics will not be prescribed over the phone. If you feel your child may need an antibiotic, he/she will need to be seen.

In case of an emergency, call 911 or take your child to the nearest hospital emergency room.

After Hours Services: After-hours contact will be the Children’s Health Network.

By signing below, you acknowledge that you have read and understand the office policies and financial policies. I accept the financial terms noted above and certify that the information contained on this form is true and correct. Furthermore, I understand it is my responsibility to present Plum Pediatrics with valid insurance information at each visit and inform Plum Pediatrics should any information on this form change at any time in the future.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. It is my responsibility to inform the doctor’s office of any changes in my child’s medical status.

I am providing Plum Pediatrics with my known primary health insurance information. I understand that if MY PRIMARY INSURANCE FINDS OTHER HEALTH INSURANCE, they may deny paying any office visit claims. I understand that Plum Pediatrics DOES NOT file secondary insurance and that I must file my own claims with my secondary insurance. I understand that I will be completely responsible for all charges and will pay in full. ALL INSURANCE CARDS MUST BE PRESENTED in order for us to file claims. This form is NOT CONSIDERED valid to file claims with your insurance company.

I acknowledge receiving a copy of the Notice of Privacy Practices given to me by Plum Pediatrics and understand that Plum Pediatrics reserves the right to modify the privacy practices outlined in the notice. I understand this Notice explains how Plum Pediatrics is permitted to Use and Disclose my Protected Health Information. Plum Pediatrics may use and disclose protected health information (PHI) about me and my child to carry out treatment, payment, and healthcare operations as described in our Notice of Privacy Practices (NPP). Plum Pediatrics may call my home or other designated location and leave a message on voicemail or in person in to any items that assist the practice in carrying out treatment, payment and healthcare operations. This may include appointment reminders, insurance items, laboratory results and any call pertaining to my child’s clinical care. Plum Pediatrics may mail to my home or other designated location any items that assist the practice in carrying out treatment, payment and healthcare operations. This may include appointment reminder cards, and patient statements. Plum Pediatrics may email any items that assist the practice in carrying out treatment, payment and healthcare operations. This may include appointment reminders, insurance items, laboratory results and any call pertaining to my child’s clinical care. I understand I should keep the Notice and refer to it if I have questions. This agreement is in effect without any expiration unless I revoke my consent at any time in writing. Revoking my consent does not apply to the Protected Health information that has already been disclosed for normal agreed upon practice operations. I also understand that Plum Pediatrics reserves the right to refuse requested restrictions. I also understand I should call Plum Pediatrics at (469) 864-7586 if I have a question or concern about my privacy rights.