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Pediatric Health & Wellness

Proudly Part of Privia Health

Patient Forms

Authorization for Release of Medical Information (PDF) - Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. Autorización De HIPAA Para Divulgar Información Del Paciente

Authorization and Consent for Treatment (PDF) - All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento

Preferred Contacts (PDF) - Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos

Virtual Visit Policy (PDF) - This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.

Office Policies

Financial Policy (PDF) - This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations. Política Financiera (PDF)

Notice of Privacy Practices (PDF) - Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully. Aviso de prácticas de privacidad (PDF)

HIPAA Privacy Notice

Additional Patient Forms

Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.

Additional Office Policies

We are honored that you have chosen Pediatric Health & Wellness for your child’s healthcare. To ensure a smooth and positive experience for your family, please review our office policies below.

  1. Office Hours & Appointments
    • Hours: Monday - Thursday 08:00 AM - 05:00 PM, Friday 08:00 AM - 04:00 PM; closed weekends and major holidays
    • Appointments: Walk-ins are welcome for acute visits although “calling ahead” is always more helpful for our staff.  Well visits must be scheduled in advance.
  2. New Patients
    • New patients must complete all required forms before the first visit.
    • Please arrive 20 minutes early to allow time for check-in and verification of insurance
    • Bring your child’s immunization records and a list of current medications.
  3. Cancellations & No-Shows
    • Kindly give at least 24 hours’ notice to cancel or reschedule
    • No-shows or late cancellations (less than 24 hours) may result in a $25 fee
    • After 3 missed appointments, we reserve the right to discharge your family from the practice
  4. Late Arrivals
    • Patients arriving more than 15 minutes late may be asked to reschedule to avoid delays for others
  5. Insurance & Payments
    • We accept most major insurance plans. Please notify us of any changes.
    • Copays, deductibles, and outstanding balances are due at the time of service
    • We accept cash, debit, credit, and HSA cards
  6. Vaccination Policy
    • We follow the CDC-recommended immunization schedule but also respect your right to decline vaccinations
  7. Prescription Refills
    • Please allow 48 business hours for medication refills. Call during business hours or use our patient portal.
    • We do not refill medication after hours or on weekends.
  8. Forms and Paperwork
    • Please allow up to 5 business days for form completion which includes forms for school, daycare, camp, and sports teams.
    • FMLA paperwork is completed at the discretion of the provider.
  9. Communication
    • Non-urgent questions can be submitted via the patient portal or by calling during office hours.
    • Emergencies: Call 911 or go to the nearest emergency room.
    • After-hours: A provider is on-call for urgent medical issues only. Please call our main number for instructions
  10. Behavior Expectations
    • We strive to maintain a respectful and safe environment. We expect families to treat staff and providers with courtesy.
    • Disruptive or abusive behavior may result in dismissal from the practice
  11. Confidentiality
    • We comply with all HIPAA regulations. Your child’s health information is protected and shared with your consent or as required by law.
  12. Divorced, Separated, or Unmarried Parents
    • Our providers do not get involved in custody disputes. We act in the best interest of the child.
    • The parent or guardian accompanying the child to the appointment is responsible for copays and fees due at the time of service, regardless of custody or financial arrangements.
    • We will not restrict access to a child’s medical information unless we receive official court documentation indicating such limitations.
    • It is the responsibility of both parents to communicate with each other about the child’s care, appointments, and treatment plans.
    • We ask that both parents respect the child’s experience by keeping conflicts or legal matters outside of the clinical environment.