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Office Policies

Our set of general guidelines that outline our organization’s plan for tackling issues

Office Policies


Medical information is released only with your consent. We’re required by the Health Insurance Portability & Accountability Act (HIPAA) to request you to sign forms addressing consent for disclosure and acknowledgment of understanding.

Permission to See

Patients under 16 years of age should be accompanied by a responsible adult guardian. Patients unaccompanied by a parent or guardian need to provide a letter addressing “permission to be seen,” which is written and dated by a responsible party.

Adolescent Care

Patients turning 13 years of age are offered the opportunity to complete a separate questionnaire from the one completed by their parent(s) and to undergo a private examination without their parent(s). Parent(s) and adolescent are brought together after the examination to discuss selective issues.


Our office is a non-smoking area. To respect the health of other children and the cleanliness of our building, please refrain from smoking near the entrances and keep our grounds free of cigarette butts and other debris. Exterior trash cans are provided.


No appointment is necessary for our sick, acute care clinic and your child will be seen by the first available provider. Well child or chronic disease appointments Monday through Friday or non urgent sick appointments should be scheduled in advance and cannot be seen during walk in clinic.

No-Show Fees

Parent(s) of patients not showing up for a prescheduled appointment will be charged a $65 fee. Patients arriving 15 minutes late for appointments will be seen if the provider is available; otherwise, they may have to be rescheduled into a later appointment or another convenient time.

Financial Responsibility

Children’s Health Services patients (or their legal guardians) are responsible for paying for the services they receive in full at the time of service. If you have health insurance, you must pay the entire co-pay amount or an estimate of your deductible on the day of your appointment. We employ an outside billing company that will file an insurance claim directly to your insurance company for the remaining portion. If there is still a balance remaining after the insurance company has processed the claim, payment is due in full from the patient upon receiving a billing statement. Please note: if your balance is under $20.00, you will not receive a billing statement, but are still responsible for paying this balance. Our policies regarding financial responsibility are outlined on our Patient Payment Policy form.

Waiting Areas

Our office has separate waiting room areas for sick and well children and check-in/check-out windows. We also offer private breast feeding rooms for the comfort and privacy of nursing moms. Please try to limit the number of people accompanying your child to provide space for other patients and their families.


If your insurance requires pre-certification prior to elective outpatient procedures, referrals to specialists, prior to hospitalization or x-rays, please notify our office several days in advance so that we may obtain the medical approval in time.

Behavioral Assessment Form

Newborn Vitamin K Policy

Vaccinate Policy

Refusal to Vaccinate Patient Forms

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