Patient Forms

Save time by filling out paperwork before you come to our office! You can fill out our main information form below, and we’ll have it ready for your visit. Other forms are available to download/print, as well.

Intake Form

Step 1 of 6

Parent/Guardian Information
Please list the information for each parent/guardian.
First Parent/Guardian Name*
First Last
Birthdate*
Mobile Phone*
Work Phone
Same address as child(ren)?*
- Yes
- No
Address*
Street Address Address Line 2 City State ZIP Code
Employer*
List as account guarantor?*
- Yes
- No
Second Parent/Guardian Name*
First Last
Birthdate*
Mobile Phone*
Work Phone*
Same address as child(ren)?*
- Yes
- No
Address*
Street Address Address Line 2 City State ZIP Code
Employer*
List as account guarantor?*
- Yes
- No
Alternate/Emergency Contact
Other than Parent
First Last
Alternate Contact Phone
Relationship to Patient

Insurance Information
Primary Insurance
Insurance Company*
Policy ID*
Group Number*
Policy Holder/Subscriber*
First Last
Date of Birth*
Secondary Insurance
Insurance Company
Policy ID
Group Number
Policy Holder/Subscriber
First Last
Date of Birth
ASSIGNMENT OF INSURANCE BENEFITS/ CONSENT TO TREAT/ PRIVACY POLICY*
I understand that I am financially responsible for all professional charges that my children may incur. All copayments and non-covered charges are due at time of service. All costs not paid by insurance are due upon receipt of statement. I hereby authorize payment of medical benefits direct to Pediatric Associates P.C. I further authorize the release of any medical information necessary for processing the insurance claim. I understand that all costs not paid by insurance are my responsibility unless otherwise prohibited by state or federal regulations. Permission to Treat Minor (under age 18): In the event of an emergency and I cannot be contacted, I give my permission to treat my child in their office as required by the events of an emergency. Acknowledgement of receipt of HIPAA Notice of Privacy Practices: I have received or have been given the opportunity to receive a copy of HIPAA Notice of Privacy Practices for Pediatric Associates PC.
I agree.

Pediatric Associates P.C. Financial Policy
Pediatric Associates P.C. is dedicated to providing excellent care and understanding overall service to every patient at every visit. In the interest of avoiding misunderstandings that may arise due to any financial matters, please take note of our financial policy and sign below if you are agreeing to be bound by these terms:

Our office participates in most major health plans, but please remember:
- It is your responsibility to verify that the pediatrician is a participating health care provider in your health plan. This should be done prior to making an appointment.
- Identification and the patient’s insurance card must be brought to each visit so that we can ensure that we are billing the most current insurance plan.
- The insurance policy holder’s/grantor’s date of birth and social security number are required for account verification.
- It is your responsibility to know your benefits and to understand that if services rendered are applied to your deductible or considered non-covered services, you will be responsible for payment.
- Co-pays are due at the time of service.
- Any care not paid for by your existing insurance coverage will require payment in full at the time services are provided or immediately upon notice of an insurance claim. You are responsible for communication with your carrier regarding denied claims.
- Self-Pay patients are required to pay for the service in full at the time of visit.
- A $10.00 fee will be charged for the completion of each form that is not requested during the preventative check.
- A medical records fee may apply for records requests and will be priced at allowed state rates.
- Courtesy Appointment reminder calls are made to confirm appointments. It is your responsibility to keep account information up to date. A 24-hour notice is required if you need to cancel an appointment. If sufficient notice is not provided, you could be considered a "no show” and a $25.00 “No Show Fee” or a $25.00 “Rescheduling Fee” will be applied.
- All balances are due within 30-days of the first statement. Please contact our Billing Office at 804-3207139 if you have any concerns regarding your bill so we can assist you. If a payment is not received in full within 60 days a $10.00 late fee will be charged.
- Delinquent accounts more than 90 days past due, with no payments and/or broken payment arrangements are subject to collection activity. You will be notified by phone or in writing prior to collections.
- In the unfortunate event that we need to assign an account to a collection agency, an additional fee of 40% will be added to the delinquent balance on the account. Any discounts will be added back to the balance and the amount sent to the collection agency will be the full fee.
- Existing patients with delinquent accounts, accounts turned to a collection agency, active bankruptcy claims or have balances written off to bad debt may not be seen at a Pediatric Associates PC office until such debt is satisfied or a payment arrangement is in place.
- Returned checks will be assessed a $50.00 returned check fee and we retain the right to refuse payment by check for future appointments.
- Repeat violators of these policies could be dismissed from our practice.
Should you receive a bill from us, and you find yourself in a financial bind, PLEASE call us to discuss setting up a payment plan. If more charges are added to the balance, new payment arrangements will need to be made. We are happy to help and are here to assist you.
Agreement*
By agreeing, I acknowledge that I have read, understood, and agree to pay for all services rendered in accordance with the terms set forth in the financial policy of Pediatric Associates PC.
I agree.

PERMISSION TO TREAT
Patient Name
First Last
Date of Birth
Guarantor Name
First Last
Relationship
Additional Children Seen at Practice Granted Permission:
Please list one per line.
In the event I am unable to be physically present at my child’s appointment, I give permission for the following person(s) to legally give surrogate consent for the evaluation and treatment for my child. This includes exams, diagnostics, vaccinations, medications, and minor procedures. I agree to assume all financial responsibility for any charges arising as the result of such consent and treatment. This consent is valid until revoked in writing.
- Self-Transporting teenager has permission to obtain treatment without a parent physically present for the above listed care.
Name
First Last
Relationship to Child
Name
First Last
Relationship to Child
Name
First Last
Relationship to Child
Consent*
I consent to allowing the above named individuals to seek care for my child..

NO SHOW/MISSED APPOINTMENT POLICY
We, at Pediatric Associates, understand that sometimes you need to cancel or reschedule your appointment and that there are emergencies. If you are unable to keep your appointment, please call us as soon as possible (with at least a 24-hour notice). You can cancel appointments by calling the following number: Waterford Location: (804) 794-7788 / Hioaks Location: (804)320-7139.

To ensure that each patient is given the proper amount of time allotted for their visit and to provide the highest quality care, it is very important for each scheduled patient to attend their visit on time. As a courtesy, an appointment reminder call to you is made/attempted at least one (1) business day prior to your scheduled appointment. However, it is the responsibility of the patient to arrive for their appointment on time.
PLEASE REVIEW THE FOLLOWING POLICY:
1. Please cancel your appointment with at least a 24 hours’ notice: There is a waiting list to see the clinician’s at Pediatric Associates and whenever possible, we like to fill cancelled spaces to shorten the waiting period for our patients.
2. If less than a 24-hour cancellation is given this will be documented as a “No-Show” appointment.
3. If you do not present to the office for your appointment, this will be documented as a “No-Show” appointment.
4. After the first “No-Show/Missed” appointment, you will receive a letter warning that you have broken our "No-Show" policy. Pediatric Association P.C. will assist you to reschedule this appointment if needed.
5. If you have 2 “No-Show/Missed” appointments within a one-year time period, you will receive a warning letter from our office and will be assessed a $25.00 no show fee.
6. If you have 3 "No-Show/Missed" appointments within a one-year time, you will receive a second $25 no show fee assessment. Dismissal from the practice will be considered. *You will be notified by letter if the dismissal was approved.
Agreement*
I have read and understand Pediatric Associates No Show/Missed Appointment Policy and understand my responsibility to plan appointments accordingly and notify Pediatric Associates appropriately if I have difficulty keeping my scheduled appointments.
I agree.
Comments
This field is for validation purposes and should be left unchanged.

Additional Forms

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Medical Records / Form / Statement Request

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Patient Portal Access

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Financial Policy

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HIPAA Notice of Privacy Practices

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HIPAA Form A

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HIPAA Form B

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HIPAA Form C

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HIPAA Form D

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ADHD Parent Form

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ADHD Teacher Form

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VA School Entry Form

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VA School Sports Physical Form

Appointments Available Every Weekday & Saturday

We are open every weekday from 8:00am to 5:00pm and have sick appointments available daily. On Saturdays, our Waterford office is open starting at 8am for sick visits (by appointment only).

Patient Forms

Intake Form

Step 1 of 6

Children's Information

Child 1

Child 2

Child 3

Child 4

Parent/Guardian Information

Insurance Information

Primary Insurance

Secondary Insurance

Pediatric Associates P.C. Financial Policy

PERMISSION TO TREAT

NO SHOW/MISSED APPOINTMENT POLICY

PLEASE REVIEW THE FOLLOWING POLICY: