New Patient Form

Thank you for choosing West Coast Pediatrics as your child's primary care physician. The following packet has been compiled by our staff to gain sufficient information for the proper care of our new patients. Please read and fill out this packet carefully and fully to understand our office policies. Sign and date all appropriate spaces.

The receptionist will require a copy of the patients' insurance card, updated immunization record, applicable co pays and a photo identification of the responsible party. We are looking forward to building a long, happy relationship with your family.

Thank you for your cooperation and welcome to our practice!

Form Instructions: Please complete all the forms below as much as you can

Child 1

Child 2

Child 3

Child 4

Child 5

Insurance: PLEASE PRESENT CARD TO FRONT DESK

Primary Policy

Pharmacy Information

Mom/Guardian

Dad/Guardian

Additional Contact Questions

Thank you for choosing West Coast Pediatrics for your child's medical needs. We are committed to providing you with exceptional medical care, as well as, making our medical billing processes as simple and efficient as possible. Recent shifts in the healthcare industry have resulted in insurance companies increasing the patient's portion of the payment. Please take a moment to familiarize yourself with our practice’s “EASY-PAY” — A Credit Card on File Policy.

To streamline our payment system and provide a convenient way for parents to pay their bills , effective September 1, 2019, we will require all patients to keep an active credit card on file with us. The credit card information will be stored in a secure vault by our payment processor. We will bill your insurance company first and upon their determination of benefits we will charge your credit card for patient portion of the payment. Circumstances, when your card would be charged, include but are not limited to: missed co-payments, deductible and co-insurance, non-covered services and/or denial of services, and past due balances.

We encourage all patients who have questions or concerns about the cost of care to inquire about those costs in advance of service. West Coast Pediatrics follows the American Academy of Pediatrics, (AAP) guidelines for care provided to our patients. If deemed medically necessary, we will administer care according to those guidelines and patients will incur associated fees.

I understand and agree with the following financial policy of West Coast Pediatrics:

1. All Payments for all applicable co-pays, coinsurance, and deductible are to be paid by the accompanying parent or adult responsible at the time of service. West Coast Pediatrics accepts cash, checks, and debit/credit cards as methods of payment.
2. As the guarantor, I am financially responsible for my newborn's first visit to West Coast Pediatrics unless I can show proof of the insurance
3. I understand that before making an annual physical (well-child) appointment I will check with the current insurance carrier regarding covered and non-covered charges. Not all plans cover annual hearing and vision screenings. If it is not covered, it is understood, that I will be responsible for payment on the allowable amount at the time of visit.
4. I understand that Patient(s) who are not eligible for Medicaid on the date of service will not be reimbursed for any out of pocket expenses. This includes retroactive Medicaid plans. By signing this policy I am consenting that West Coast Pediatrics is not responsible for submitting retroactive patient claims to Medicaid.
5. As the guarantor, I will be responsible for all charges that are not covered by my insurance company. If my insurance is terminated, I as the guarantor will be responsible for all charges incurred with West Coast Pediatrics.
6. If there is a balance on my account, I must pay the balance in full within 30 days. I understand that if the balance is 30 days past due I will be charged an administration fee of $25.00 each month until the balance is paid in full.
7. In the event that my account is sent to an outside collection agency, a 35% collection fee will be charged to my account before it is turned over to a collection agency. If my account is sent to an outside collection agency, I will be dismissed from the practice.
8. I must notify the office of any change of address, phone number, and insurance information.
9. I authorize the submission of a claim and direct payment to West Coast Pediatrics for all services provided to the above patient. When a claim is submitted as an unassigned claim, I also authorize payment to be issued directly to West Coast Pediatrics for the amount due in my pending claim for services of medical treatment to the above patient.
10. If my child needs to be seen by a specialist, I must obtain proper authorization and understand that I am financially responsible to the specialists. I must call the specialist and make the appointment and notify West Coast Pediatrics of the appointment to ensure that proper authorization is obtained with a 48-hour advanced notice.
11. In the event, I can't be present during a visit, I will send written authorization with the adult/guardian that is with my child.
12. In the event of a NO Show, there will be a $25.00 fee assessed on the above patient's account. After 3 No Shows you may be dismissed from the practice.
13. I understand that WCP doesn't accept secondary insurances and it is my responsibility to bill my secondary insurance.

West Coast Pediatrics is committed to providing the best medical care for our patients and we charge what is considered “usual and customary” for our demographic area. You as the guarantor are responsible for payment if there is any private insurance companies’ arbitrary determination of “usual and customary” rates.

We understand that situations arise in which you must cancel your appointment. it is therefore requested that if you need to cancel your appointment, please provide more than 24 hours notice. This will enable another person who is waiting for an appointment to be scheduled in that appointment slot.

If you call for a SAME Day Sick visit and no show you will be charged $40.00

Office appointments which are canceled with less than 24 hours notification will be subject to a $25.00 cancellation fee.

Parents who do not show up for their appointment without a call to cancel an office appointment will be considered as NO SHOW. A $25.00 no show fee will be charged to the account.

Our practice firmly believes that good physician/patient relationship is based upon understanding and good communication.

We understand that Special unavoidable circumstances may cause you to cancel within 24 hours. Fees in this instance my be waived but only with management approval.

These fees are not covered by insurance, they are the sole responsibility of the patient/family and must be paid in full before the patient's next appointment.

Questions about the cancellation and no show fees should be directed to the Office/Billing Manager at 941-761-0663

I authorize West Coast Pediatrics including its employees, to release, obtain and/or use general medical, psychiatric/psychological, legal, alcohol, and/or drug abuse information pertaining to

Purpose of Release

☑ Treatment Planning
☑ Reimbursement
☑ Psychological Evaluation
☑ Consultation
☑ Legal

1. I understand that authorizing the disclosure of this health information is voluntary and you have my consent to release medical records for all dates including all diagnostic tests for any type and reports, history, hospitalization, diagnosis, prognosis, treatment, medication and pharmacy records, correspondence, consults, statement of charges or expenses. Any and all reports of any type or character.
2. I understand that the information authorized for release may include records which may indicate the presence of a communicable or non-communicable disease.

This authorization will expire one year from the date signed. A copy or facsimile of this authorization shall be counted true and valid as original.

I give permission for the medical staff to contact me at the following numbers regarding patient care, test results, appointments, prescription and billing questions.

I hereby authorize West Coast Pediatrics to treat my child and discuss appointments and test results with these designated persons: