New Patients
Please download and complete forms listed, and bring to your FIRST APPOINTMENT:
Patient Information Form
Medical History Form
Medical Authorization Form
General Policy
Financial Policy
Full Immunization Policy
GENERAL and FINANCIAL POLICY
Thank you very much for choosing Fayetteville Children’s Clinic, P.A. as your child’s healthcare provider. We are committed to providing high quality medical care and look forward to partnering with you in caring for your child. Our financial policy, as well as your responsibilities are outlined below.
IMMUNIZATION POLICY: We require all our patients to be immunized as recommended by the CDC and required by the State of North Carolina. We will not accept as patients those children whose parents choose not to immunize or choose to delay immunization contrary to our doctors’ advice.
AFTER-HOURS CALLS: Please call our regular clinic number if you need urgent medical advice after hours. An operator will connect you with a triage nurse as appropriate. We ask that you consult our website or call during our regular business hours for non-emergent medical questions, form completion, medication refills, appointment scheduling, referrals and such.
REFERRALS: We provide referrals for our established patients and help find a specialist or testing facility based on recommendations from our doctors. An office visit might be required to initiate the referral or testing. Please allow 7-10 business days to process the referral.
PRESCRIPTION POLICY: Please allow 48 hours for most medication refills. An office visit may be needed to determine whether a refill is appropriate. Medication refill requests cannot be addressed outside of our regular business hours. To ensure your child’s safety, we may not prescribe a medication over the phone. Please call our office for an appointment if you believe your child is sick enough to need a prescription.
FORMS AND LETTERS: We require 48 hours to complete most forms (more complicated forms and letters may take longer). Starting July 1, 2024, there will be an administrative charge of $10 associated with completion of each medication authorization form, asthma action plan or allergy action; as well as a $25 administrative charge for forms requiring extra time (such as FMLA, EFMP or letter of medical necessity), due at the time of pick up. Due to HIPAA law, we cannot fax your child’s forms to daycares and schools.
SATURDAY APPOINTMENTS: We provide walk-in urgent care to our established patients on Saturday mornings between 9:30 – 11:30 am. There is an additional $35 fee for all Saturday visits which cannot be waived.
NEBULIZERS AND SPACERS: As a service to our families, we provide nebulizers and spacers to our patients with respiratory issues. The equipment is supplied by Active Healthcare, Inc. They will bill your insurance company directly. Please contact Active Healthcare, Inc. at 919-870-8600, ext. 83, to verify your insurance benefits including deductibles, coinsurance and out of pocket costs. You may call them within 48 hours of receiving the equipment to et a private pay cash price, with no insurance filing.
MUTUAL RESPECT: We expect our staff to treat each and every patient and family member with utmost respect and compassion. In return, we expect the same from our patients and families. Those who show unacceptable behavior may be asked to seek care elsewhere.
FINANCIAL POLICY
HEALTH INSURANCE, CO-PAYS AND DEDUCTIBLES: Our office contracts with a variety of insurance companies. In accordance with our agreements, co-pays and deductibles are expected to be paid on the day of service and cannot be waived. Please be ready to provide your current insurance card at every appointment. If we are unable to verify your insurance coverage on the day of your visit, you will be considered a self-pay patient. If a health problem is addressed during a well-child check, a co-pay may be required. As a convenience, we accept Visa, MasterCard, debit cards, cash and checks. A $25 fee will be added to your account for each returned check.
NEWBORNS: Parents are advised to a dd newborns to their insurance policy as soon as possible. If we are unable to verify your baby’s coverage prior to their 2-month well check visit, the appointment will have to be rescheduled until coverage is in effect. Alternatively, you can be seen as a self-pay patient, with payment expected in full at the time of service.
OUT OF NETWORK: If your insurance considers us out-of-network, you are responsible for payment in full at the time of service. We will gladly provide you with proof of visit and a receipt so that you may file for your reimbursement.
SELF-PAY: If you do not have health insurance, you will be considered a self-pay patient and will be required to pay for all services at the time they are rendered. If interested, please call prior to your appointment for a good faith estimate of the charges.
DIVORCED PARENTS: In case services provided for minors, the individual initiating the medical care for the child will be responsible for any payment at the time of service. Fayetteville Children’s Clinic will not act as a mediator in collecting payments. Also, we require a copy of the up-to-date court ordered custody agreement.
NO-SHOW, LATE AND CANCELLATION POLICY: We strive to provide appointments as needed for all our current patients, whether it be a well or sick visit. As a courtesy, we provide text message or phone call appointment reminders at least 2 days before scheduled appointments. At least one (1) business day notice is required for all canceled and reschedule appointments. Starting JULY 1, 2024, failure to notify the office one (1) business day in advance will result in a $50 fee. Emergencies will be considered on a case-by-case basis for a waiver of this fee. If you arrive more than 15 minutes late for your appointment, you may be asked to reschedule. Repeated no-shows will lead to the family’s dismissal from the practice.
PAST DUE ACCOUNTS: We expect that you will make every effort to pay your bill promptly. Please, call our office if you experience financial hardship. If no prior arrangements have been made, your account will become delinquent when past due 90 days and may be turned over to collections and/or you will be discharged from the practice.
