Forms & Documents

To download the forms and information you need, simply expand each category title and select the form title.

New Patient Forms have been updated as of 10/5/2020. 

Our patients have the following rights to privacy and respect regarding their personal information:
  • The right to access and copy health records with reasonable notice.
  • The right to request amendment or correction.
  • The right to an accounting of disclosures.
  • The right to specify how confidential information is communicated.
  • The right to request restriction on how health information is disclosed or used.
  • The right to file a compliant if they believe that our safeguards and procedures have not been followed.
  • To view our Patient Non-Discrimination Policy, please click here (PDF)

INSURANCE AND OTHER PATIENT RESPONSIBLITIES

CANCELLATION, NO SHOW AND ER POLICY

Any privacy issue complaints should be directed to the Privacy Officer. If satisfaction is not received, the patient may notify the Department of Health & Human Services.

In consideration of the services provided to the patient, the parent/guardian is directly and primarily responsible to pay the amount of all charges incurred for services (including laboratory testing and radiology) and procedures rendered at Angel Kids Pediatrics. You are responsible for any applicable deductible, co-insurance or co-payments prior to the provision of services.

Angel Kids Pediatrics may file a claim for payment with my insurance company as required by contractual agreement. If the insurance company fails to pay Angel Kids Pediatrics in a timely manner for any reason, then I understand that I will be responsible for prompt payment of all amounts owed to Angel Kids Pediatrics. Should the account be referred to a collection agency or attorney for collection, the undersigned shall pay all costs of collection, including a reasonable attorney’s fee. The billing department and/or office mangers handle financial matters, not the doctors. Angel Kids Pediatrics will still collect the applicable co-pays, coinsurance, and deductibles at the time of service from the Presenting Guardian. Please direct your questions accordingly. Settlements/financial responsibilities, such as divorce, must be resolved between parents. We do not get involved with these issues.

PRIVACY POLICY AND FINANCIAL AGREEMENT

For special forms to be completed, you will be charged $25.00 per form. Physical and shot record forms requested after the well-exam visit will incur a charge of $10.00 per set. This fee must be paid in full prior to receiving the completed forms. Angel Kids Pediatrics will not hold the liability of faxing or mailing any forms. Please give us 48-72 hours’ notice when requesting forms so that we have adequate time to prepare them.

It is the parent/guardian’s responsibility to provide Angel Kids Pediatrics with a copy of my child’s current insurance card. If you do not have insurance, you will be considered a Private Pay (or Self Pay) patient and are financially responsible for the total amount of the services provided. You must notify Angel Kids Pediatrics immediately upon any changes with your insurance.

INSURANCE AND OTHER PATIENT RESPONSIBLITIES


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