Forms

Please fill out our registration form before the first appointment or update your information before your visit to the office.

 

NEW BABIES: PLEASE SUBMIT ONLY AFTER YOR BABY IS BORN!

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Policies

Billing questions? Contact us at                  rpedsbilling@gmail.com

Payment Policy: Patients are required to show their health care coverage ID card at each visit when registering. It is your responsibility to inform us before your visit of any change in your insurance so that you do not incur uncovered expenses. HMO or PPO co-payments are due at the time of the visit. If we submit a bill to your insurance company, after receiving their statement, we will ask you for payment for any uncovered services, co-payments or deductibles. If your insurance fails to respond within a reasonable amount of time, we will transfer the balance to you and expect payment. Be sure to keep track of all insurance statements. 

 

Additional Fees: 

  • The charge for any bounced check is $40.

  • There will be a $5 bill home charge for co-payments not paid at the time of service.

  • There will be a $50 charge for no show visits which includes wellness visits, ADHD follow ups, and Asthma follow ups.

  • A $10 charge will be applied when transferring records out.

  • A copay will apply to any vaccine office visit with a medical assistant.

 

New Parents and Guardians: You must call your insurance company and enroll your child within 30 days of the child's date of birth, otherwise you will be responsible for all charges.

List of Participating Insurances 

Vaccine Policy 

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