Patient Forms and Information

1. Understand your insurance policy! Most plans have co-payments, deductibles, and/or coinsurances that are your responsibility at the time of your appointment. You or the authorized adult accompanying your child is responsible for full payment of the bill at the time of service. We accept cash, personal checks, Visa, MasterCard, American Express, and Discover. If a check bounces, you will be charged an additional fee of $35.00. Co-payments not collected at the time of the appointment may be subject to a fee.

2. It is your responsibility to provide us with the most current insurance information. If the insurance information you present is outdated or incorrect, you will be responsible for the full cost of the visit and to submit the charges for reimbursement to the correct insurance plan.

3. Your insurance contract is between you and your insurance carrier. The benefits packages provided by insurance companies vary from plan to plan. While we make an effort to verify your coverage, we are not liable to guarantee that the information given to us by your insurance is correct. It is your responsibility to know what services may or may not be covered by your insurance. Any service that is performed, but not covered by your plan, will be your responsibility. Please note: We will not change our diagnosis to allow coverage.

4. Certain policies require you to select a Primary Care Physician (PCP). Please call your insurance provider before your visit and select our practice; if they have not been notified, you may be financially responsible for your appointment and/or your appointment rescheduled.

5. If you are insured by a non-participating carrier, we still expect payment from you at the time of service, and you are responsible for submitting any claims to your insurance company for reimbursement. We will provide information to assist you in this process.

6. If you require referrals for a specialist visit, you are required to know ahead of time. We require at least 3 business days to complete prior authorizations for medications and services and/or referrals. No retroactive referrals are available.

7. Any balance over 60 days will be forwarded to a collection agency.

8. We charge $20.00 per child for each copy of medical records.

9. We are happy to complete forms for school, camp, etc. The charge is $10.00 for physical forms, $20.00 for other school forms, and $25.00 for FMLA paperwork. Payment is due when the forms are dropped off. The turnaround time for forms varies based on what type of form is needed. Please ask our staff when your specific form will be available. If your child has not had a physical within the last year, please schedule an appointment so that we can complete the form with current information.

1. Before scheduling your child's annual physical appointment, we recommend contacting your insurance company to familiarize yourself with the services that will be covered at this type of appointment. Not all plans cover vision and hearing screens, urine screening, questionnaires, immunizations, flu shots, etc., as well as the physical exam. It is your responsibility to know your insurance benefits. If services are not covered, you will be responsible for payment at the time of the visit, along with any remaining balance from services performed that were not covered by your plan.

2. Well and Sick Visits: Your insurance policy may cover sick and well differently, so you must familiarize yourself with your coverage. For example, your policy may cover 100% of the cost of well visits, but sick benefits may include co-insurance, deductibles, and/or copay. If your child is sick during a well visit and needs medical attention and/or treatment, your provider may bill your insurance company for both a sick and well visit. Additionally, the provider may reschedule the well visit and treat the sick issue instead. In this case, please be aware that you will be responsible for your portion of the sick visit cost.

3. If you are unable to keep your scheduled appointment, we require you to contact our office within 24 hours before your appointment to reschedule or cancel. This will allow us to have another patient who needs that appointment come in. Continuous no-shows without calling to cancel may result in a fee and/or dismissal from the practice. 

4. Due to the high demand for appointments, we will not reschedule new patients that NO SHOW their appointment.

5. We understand that your time is valuable. We make every effort to see all patients on time. In order to provide you with prompt service, we need you to arrive 10 minutes prior to your scheduled appointment for every appointment. If you are more than 10 minutes late, you may be asked to wait or reschedule your appointment.

The staff and providers of Arizona Kids Pediatrics are focused on the medical, emotional, and psychological health of your child(ren) – NOT legal issues involving divorce, custody, or separation agreements. That is why we ask you to read the following:

1. Please make decisions regarding vaccinations, reproductive education, circumcision, etc. prior to your appointment.

2. Either parent/legal guardian is allowed to schedule appointments, accompany the child, and/or obtain a copy of visit summaries. Unless there is a court order in our records that restricts a parent's rights, please do not ask us to restrict the other parent's involvement.

3. We will collect full payment (deductibles, co-pays, etc.) at the time of service from the parent accompanying the child. If the divorce decree requires the parent not present to pay a part or the entire bill, the authorizing parent is responsible for collecting payment from the other parent. We will not collect payment from the other parent for you.

4. Both parents/legal guardians are allowed to sign an "Authorization for Medical Care" form. This means other persons (such as nannies, grandparents, etc.) can be authorized to accompany your child to appointments and consent for treatment. Both parents/legal guardians are allowed to see the names of authorized persons on each other's forms. Unless instructed by the Court, please do not ask us to eliminate any names on the other's form. If you have legal concerns regarding a certain authorized person, please refer these requests to your lawyer.

5. Additionally, we will not:

• Call to inform the other parent of appointments or to ask for consent prior to treatment.

• Tolerate appointment scheduling/cancelling patterns between parents.

• Prevent either parent's/legal guardian from making decisions, authorizing treatment, or being involved in your child(ren)'s care, unless required by law.

1. It is both parents’/ guardians’ responsibility to communicate with each other about the child's care, appointments and other important information. We will not call the other parent for you.

2. Should issues between parents disrupt our practice or impede the care of children, we reserve the right to discharge your family from further treatment.