Forms & Policies

Before your child’s appointment with us, quickly and conveniently access patient forms from our practice. To download the forms listed below, you will need Adobe Reader.

Please bring your completed forms with you to our office at the time of your child’s visit.

Download Patient Forms

• Medical Records Request
• New Patient Forms To Be Done In Office Via Tablet
• Medical Records Release
• ADHD Initial Assessment
• ADHD Follow-Up
• FHSAA Sports Form
• Patient Portal Access Request Form

Influenza Vaccination Forms

• Vaccine Information
• Influenza Vaccine Consent Form

Office Policies for Current Patients

CHECK IN:

Upon arrival, please sign in at the reception desk and be prepared to present your picture ID and Insurance card and/or Medicaid cards at each visit.

INSURANCE and PAYMENT:

Your copay is due at the time of each visit and does not include other charges that your insurance company deems to be your responsibility. This includes, but is not limited to, deductible or co-insurance. Any outside balances are due upon receipt of your statement. If you have questions about what your insurance plans covers, please call your insurance carrier.

ARRIVAL/LATE ARRIVAL:

We ask that you arrive 15 minutes prior to your appointment time. Please help us maintain our schedule by being on time for your appointment. If you are going to be late for your scheduled appointment, please call to confirm that your provider will be able to see you.

NO SHOW/CANCELLATIONS:

If you find you cannot keep your scheduled appointment, we require notification 24 hours in advance or you may be charged a fee of $40.00. In consideration of other patients and staff, it is necessary that no shows are avoided. If you do not show up for your appointment, it is our policy to charge the $40.00 fee each time it occurs. These fees are not covered by your insurance and are due and payable upon your return visit. If you have more than 3 cancellations or No-Show appointments, this can result in dismissal from this practice.

PRESCRIPTIONS/REFILLS:

Please contact your pharmacy for any prescription refills. At the time of your office visit, our providers make every effort to ensure you are provided with enough refills to last until your next scheduled appointment. If a situation should arise in which you are not able to make your scheduled follow up appointment, please contact our office as soon as possible. If you are unable to reschedule your appointment before you run out of medications, your provider will consider whether or not an exception can be made. If a prescription is written by a physician outside of your primary care physician’s office, it will only be authorized for refill after evaluation and management of that condition by one of our medical providers.

CONTROLLED SUBSTANCES POLICY FOR NEW PATIENTS:

For chronic pain that requires monthly opioid medications such as Percocet or Hydrocodone, you may need to be managed by pain management. For severe anxiety that requires monthly prescription of Benzodiazepines such as Xanax or Clonazepam, you may need to be seen by a psychiatrist.

MEDICAL FORM/LETTERS:

Our office requires that ALL patients are up to date on physical wellness exams before physical forms are completed. Forms are completed during your office visit. Some forms not able to be completed during your visit will require a fee for completion.

REFERRALS:

To process a referral for a new complaint or complaint that has not been recently evaluated, you will need to schedule an appointment. If you are referred to a specialist for either treatment or a diagnostic test, please allow 3-5 business days for this information to be processed with your insurance company. The information will be sent directly to the specialist and the specialist will be contacting you for an appointment. If you have NOT heard from the specialist within 7-10 business days of being seen in our office, please contact our office so that we may assist you in getting the necessary appointment.

AFTER HOURS:

If you are in need of medical attention when our office is closed, please call our office line and speak with our After Hours Service. These calls are handled by Medical Staff and Physicians who can advise you until you can either obtain an appointment in our office or to seek immediate attention in the nearest emergency facility.

APPOINTMENTS:

For new medical issues or to review labs that require speaking to the physician or mid-level provider, you will need an appointment. This allows you to be appropriately evaluated and treated. All requests for antibiotics require appointments. For most chronic stable medical problems, you will need to be seen every 3-6 months. This allows for appropriate monitoring and management of your medical problems. For unstable problems, you will need to be seen more frequently.

COMPLIANCE EXPECTATIONS:

Providing quality patient care is our top priority. During your visit a treatment plan will be agreed upon by you and your provider. It is important for both preventive and therapeutic purposes that you comply with completing any orders, testing, referrals, follow-up appointments, etc. that were outlined by your provider and within a timely manner. Patients who are noncompliant may be dismissed from the practice.

COMMUNICATION:

Our office encourages you to communicate through the patient portal. All communication will be reviewed and direction given to the medical assistant to communicate the patient instructions.

BEHAVIORAL EXPECTATIONS:

Our staff and doctors believe respect is the basis of a good relationship. We will treat you with respect and compassion. We have an expectation that our patients will also be respectful towards our staff and physicians. If you are not able to comply with this courtesy, you may be asked to leave the practice.

Contact Orange Park Pediatrics for more information or to schedule an appointment at one of our locations.