Forms & Policies
Click here for COVID-19 Related office temporary Policies changes
General Patient Forms
- New Patient Forms Package
- Well Child Appointment Forms
- Authorization for Release of Medical Records
- Notice of Privacy Practice
- Request Medical Records to SuperKids Pediatrics
- No Surprises Act
Office Policies
With the objective of securing our patient the highest and best access to quality of care we have established polices which define our medical/patient partnership. Please review our complete policies here. Please find below some important policies/requirements:
After Hours Calls
We ask you to be reasonable reserving after hour phone calls for patients with a truly medical urgent matter and restrain any non-urgent calls to be handled during regular business hours. Please note that after hours calls without a true medical urgency may incur in a bill in the amount of $35.00 for the convenience of the service. Example of calls that will be subject to the after-hour fee are refills, appointments, school forms requests and any call relating to ongoing medical or non-medical issue that do not represent an imminent danger, significant discomfort or adverse effect.
Well Child Care (WCC) appointments
WCC is the most important appointment with your primary care provider as it provides the foundation for preventive care. We require your full commitment with all recommended WCC visits. These include WCC visits at 1, 2, 4, 6, 9, 12, 15, 18 and 24 months of life. One yearly visit thereafter. We will continue to make efforts to help you book your WCC appointments but, failing to comply will prevent us from continue to provide our services as your Primary Care Physician.
Immunization
We are not accepting new families who choose not to vaccinate their child. In an effort to increase immunity within our patients and community while preventing illness and saving lives, we will continue helping families who are delaying or choosing to perform an “alternate” vaccine schedule. However, we are establishing a limit on time delay as follows:
All patients must have completed the following vaccines by 24 months.
- Hep B 3 doses
- IPV 3 doses
- Rotavirus 2 doses
- MMR 1 dose
- DTaP 4 doses
- VAR 1 doses
- Hib 3 doses
- Hep A 2 doses
- PCV13 4 doses
For patients traveling overseas or with high-risk conditions, we might require further vaccine compliance.
Billing
SuperKids Pediatrics encourage you to know and understand as much as you can about your health insurance plan coverage and limitations. All patient responsibility is due as determine by the anticipated billing medical code(s), details of your policy coverage as you agree with your insurance. It is your responsibility to make sure your policy is active during date of service and update any changes to demographic or insurance information with the practice and any consequence arising after submitting your claim. After 90 days any balance is subject to collection services and fees. We will gladly work with you and your insurance plan to re submit, clarify and offer any assistance needed when it comes to understanding or correcting any claim.
Requesting School Forms
Upon request, we will provide a School Entry Health Exam (Form DH3040) and any available Florida Certificate of Immunization (Form DH680) at the Time of your Well Child’s Appointment. Please note that a $5 per form fee will be charged if forms are requested at a later date following the appoitment visit. If later requested, please allow 10 to 25 business days for return of your completed form. You can request an expedited service, if available at the time, for Forms DH3040 and DH680 for a fee of $20.00.
**Special school letter request (E.g. 504 plan, placement, medication) will only be address during an evaluation/follow up appointment.
We appreciate your trust in partnering with us! We promise to continue to utilize the best resources to promote the smart way of living while enhancing healthy choices in the most individualize, fun and interactive way!
