Application

Thank you for choosing Huntsville Pediatric Associates to care for your child/children. We appreciate your trust and welcome your family to our practice. Huntsville Pediatric Associates believes that a clear definition of our patient policies will allow both the patient’s family and your HPA physician to concentrate on the most important issue-maintaining your child's health.


In order to continue with the application process, please agree to our Office Policies by selecting the checkbox beside each one.



Phone hours are 7:00 am-4:30 pm Monday through Friday with appointments beginning at 8:15 am. We are open on weekends for emergencies only, our phone lines are open from 7:00 am-10:00 am.



The office is closed on all major holidays.



We strive to honor all appointments at the scheduled time. There will be occasions when your doctor may be running behind. Please be patient as we will take as much time with each patient as is necessary. If you are late, you may be asked to reschedule your appointment. If you cannot keep your appointment, please let us know immediately so others may be seen and keep our wait time to a minimum. A $25.00 fee will be assessed for any missed appointment not cancelled 24 hours prior to the appointment time.



A $20.00 fee will be assessed for appointments after 5 p.m. Monday-Friday and on Saturday and Sunday.



We see patients by appointment, we are not a walk-in clinic. When a patient presents at the front desk and requests an appointment for the same day, there will be a $10.00 fee added to the office visit.



Huntsville Pediatric Associates encourages patients to call during normal business hours. There will be a $15 fee assessed for phone calls that occur when the office is closed.



Routine refills and paperwork completion i.e. sports/camp forms, medication release forms, daycare forms etc. will be completed within 48-72 hours. FMLA forms and letters written by the physicians will incur a $25.00 charge.



Occasionally a parent will realize that a form or a prescription needs to be handled within the same business day. For these situations we will expedite your request and complete your paperwork and or prescription for a $25.00 fee.



There will be a $10.00 charge for medical/school forms, physical forms, and/or prescriptions that need to be processed at a time other than an office visit.



Huntsville Pediatric Associates follows the guidelines of the Advisory Committee on Immunization Practice (ACIP) of the Center for Disease Control (CDC) and the American Academy of Pediatrics regarding immunizations.



Our physicians do not accept patient families unwilling to adhere to these immunization schedules.



HUNTSVILLE PEDIATRIC ASSOCIATES
PATIENT FINANCIAL RESPONSIBIILTY STATEMENT

We are committed to providing your child with the best possible care. If you have medical insurance, we would like to help you receive your maximum allowable benefit. In order to achieve this we need your assistance and understanding of our payment policy. Our office participates with a variety of insurance plans, however, we are not Medicaid providers. It is your responsibility to bring your insurance card with you to every visit and be prepared to pay your copay at each visit, regardless of who brings the child in for the visit.



If you are a new parent, you will need to contact your employer and/or insurance company to inform them of the birth of your baby. If you do not contact them within the specified time frame (usually 30 days) you may be responsible for a larger financial portion of your inpatient stay and first few visits to our office.



Should your insurance carrier require you to select a primary care physician, you will need to take care of this prior to your visit in order to prevent billing problems.



Any change in insurance must be provided to our office as soon as possible in order to prevent billing problems.



We must emphasize that as medical care providers, our relationship is with you and your child, not your insurance company. While the filing of insurance claims is a courtesy we extend to our patients, all charges are your responsibility from the date services are rendered. You should be aware of your specific plan benefits, as there are many insurance benefit plans and we cannot be expected to know the specific details of each of our patient's medical plans. We advise you to fully understand your health insurance benefits as they relate to the services provided to your child. Your physician is here to provide your child with the best care possible. If services your physician feels are necessary for the treatment of conditions and maintenance of good health are NOT covered by your insurance, you are expected to pay for those services in full. If you have any questions about whether a particular service is covered, please contact your insurance company directly.



You will receive a statement from our office after we have billed your insurance.



Accounts carrying a balance for more than thirty (30) days will be assessed a monthly finance charge. If you fail to make payment in full for the services rendered, any delinquent balance will be sent to a collection agency. If your account is sent to a collection agency, your children will be discharged from the practice and you will be forced to find a new pediatrician.



By clicking below I agree to abide by Huntsville Pediatric Associates Patient's Policies and understand that by not adhering to the said policies, I can be dismissed as a patient of Huntsville Pediatric Associates.



Submission of this form does not guarantee acceptance into our practice.






All rights reserved Huntsville Pediatric Associates 2017

Care Philosphy

Our staff is dedicated to providing the highest quality pediatric care. We offer the benefits of a large office with extended hours and services, and the one-on-one personalized service you expect and deserve for your children.