APPOINTMENTS:
972-548-7888

3701 Eldorado Parkway
McKinney, TX 75070
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Pediatric Healthcare Associates, PA Office Policies, Consents & Authorizations
 
AUTHORIZATION FOR TREATMENT:
I authorize Pediatric Healthcare Associates, P.A. to provide treatment to the below named patient.

REFERENCE LABORATORY SERVICES:
I understand that Pediatric Healthcare Associates, P.A. utilizes the services of an outside lab to perform some of the lab tests requested by its physicians. I further understand that the Reference Laboratory will bill separately for its services. I consent to Pediatric Healthcare Associates, P.A., and providing demographic information as necessary for billing purposes.

ASSIGNMENT OF BENEFITS:
I authorize my insurance company to pay and herby assign directly to Pediatric Healthcare Associates, P.A. all benefits, if any, otherwise payable to me for services. This authorization may be revoked by either me or my insurance company at any time in writing.

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION:
I authorize release of copies of pertinent medical records to providers outside of Pediatric Healthcare Associates, P.A. who are being consulted with and/or I am being referred to in connection with my current treatment, to insurance companies for the purpose of determining benefits for services provided, and to reference laboratories for billing purposes.

AUTHORIZATION FOR RELEASE FOR QUALITY IMPROVEMENT:
Texas Law requires us to inform you that a copy of your medical record, no matter when created, may be released to outside groups for medical research or quality improvement purposes unless you object. Researchers cannot use patient names or identifying characteristics when reporting any results of their research. We evaluate these requests to ensure that the release of patient records is necessary to accomplish the research purpose.

AUTHORIZATION FOR REVIEW OF PRESCRIPTION HISTORY:
I authorize Pediatric Healthcare Associates, P.A. to access my electronic records of previously prescribed medications through the external electronic prescribing network, sure scripts.

USE OF DISCLOSURE OF PROTECTED HEALTH INFORMATION:
My insurer may share my past, current and future health and account records with Pediatric Healthcare Associates, P.A. about services I’ve received from Pediatric Healthcare Associates, P.A. and other care providers unrelated to Pediatric Healthcare Associates, P.A. These records may be used by Pediatric Healthcare Associates, P.A. as needed to manage or coordinate my care and to improve the quality of that care. By signing this form, I am consenting to treatment, and agreeing to all above policies. I understand this authorization will remain in effect until I revoke it in writing.

Financial Policy
 
PAYMENT IS DUE AT THE TIME OF SERVICE:
  • Payment is due regardless of who brings the child in for the service, Grandparents, caregivers, aunts, etc., payment is expected.
  • In the event that a guardian shares custody of patient, the guardian present at the time of service is responsible for payment in full at that time. If you have a court order requiring treatment costs be shared, it is the responsibility of the guardians to make appropriate arrangements prior to treatment.
  • Insurance must be provided and active in order to utilize your benefits. If insurance cannot be determined as active, patient will be considered Private Pay for that visit.
  • Financial responsibility is determined from the benefits we receive from your insurance company. Your insurance determines if you have a copay, deductible and/or co-insurance
  • Verification of insurance is not a guarantee of payment; you are still responsible for all services provided to your child, until your insurance processes and pays PHA for our services.
  • Acceptable forms of payment include cash, check, Visa, MasterCard and Discover. PHA is willing to offer payment holds or payment plans on large balances. A fee of $25.00 will be assessed to all returned payments.
NO SHOW or CANCELLATION FEES:
  • $50.00 fee applies to all Well Child Visits and ADD/ADHD visits, cancelled on same day as appointment or No Show to appointments.
  • $25.00 fee applies to all other No Show appointments.
Vaccination Policy

Pediatric Healthcare Associates, PA, does not accepts patients that do not adhere to the standard immunization schedule based on the recommendations of CDC (Centers for Disease Control) and AAP (American Academy of Pediatrics).

Exceptions to this policy should be discussed with your child’s provider regarding any deferment or delay in the vaccination schedule.

CDC and AAP recommended Immunization Schedule example:


Patient Age   Immunizations
2 Months   Rotavirus, DTaP, Hib, PCV13, IPV, Hep B
     
4 Months   Rotavirus, DTaP, Hib, PCV13, IPV, Hep B
     
6 Months   Rotavirus, DTaP, Hib, PCV13, IPV, Hep B
     
12 Months   PCV13, MMR, Varicella, Hep A
     
15 Months   DTaP, Hib
     
18 Months   Hep A
     
4-6 Years   Dtap, IPV, MMR, Varicella
     
11-12 Years   TDaP, Menigococal
     
11-12(or later)   HPV#1,2,3
     
16 Years   Meningococal

Signature of Agreement and Understanding

By signing electronically below, I am agreeing to the above Pediatric Healthcare Associates, PA: Consents & Authorizations, Financial Policy and Vaccination Policy

 
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Patient Name   DOB
 
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Parent/Guardian   Date



 
 

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