TLC and Patient Partnership Premise: TLC Pediatrics is an NCQA-certified Patient Centered Medical Home. This means that our providers form a partnership with your family to deliver exceptional care, health education and support by offering a broad variety of services that other practices may refer out to specialty care. In order for this to be possible, mutual trust must be built between the providers and patients and their caregivers. The purpose of this document is to outline the expectations of the practice and be transparent about our policies in order to help incoming families discern whether TLC’s philosophy aligns with their own philosophies.
Policies: In the following sections, please indicate your understanding and agreement with the policies as outlined.
Vaccines Save Lives: Our providers at TLC follow AAP and CDC guidelines on vaccine administration. We administer all vaccines at the intervals recommended by the CDC, as this is how the vaccines have been studied and proven to be safe and effective. We firmly believe in the safety and efficacy of vaccines, so much so that all of our own children are fully vaccinated on schedule! TLC Pediatrics does not make exceptions to the vaccine schedule to accommodate personal, philosophical or religious beliefs. Additionally, we do not write medical exemption letters for schools.
Do you agree with our policy on vaccines?* (required) Antibiotic and Medication Use : TLC Pediatrics Providers stay current on scientific evidence and follow evidence based guidelines when counseling patients. As such, our providers are very educated on which conditions warrant the use of medication, including antibiotics, and which conditions are best treated with rest, hydration and time. The overuse of antibiotics is currently actively leading to “superbugs” which place us all at risk of infections that outsmart all of the antibiotics currently on the market. As such, we ask that our families trust that we are up to date on when a medication is necessary, and will prescribe medications judiciously.
Do you agree with our policy on antibiotics?* (required) Prescription Refills: Some children require the habitual or daily use of medication. For these children, we have regular maintenance appointments, typically every 3 months, and make our best effort to prescribe enough refills to make it to the next appointment. If your child runs out of medication before the next scheduled check-in, please call your pharmacy first to request the medication, at least a week before you run out. If the pharmacy is unable to fulfill your request, please do call us, but understand that typically prescription refills are done by the provider at the end of the day, but may take up to 3-4 business days.
Do you agree with our policy on prescription refills?* (required) After Hours Care: Our providers are on call 24 hours a day, 7 days a week, via the answering service. To reach us, call our main number, (203) 855-7551, and give your child’s name and the best phone number to reach you in that moment. Our after hours line is reserved for urgent and emergent questions only. Before making a call please keep in mind that our on-call providers sleep in the middle of the night and have to get up and work the next day too! Oftentimes the answers to your questions can be found at the AAP Parent website, healthychildren.org. If it is truly urgent, please don’t hesitate to call us.
Do you agree with our "after hours" policy?* (required) Use of ER/Urgent Care: TLC Pediatrics is open 6 days a week, with providers on call at all times. We make every effort to see all sick children on the same day. As such, we expect that our patients come in for same-day sick visits, or that our families call after hours for guidance prior to going to Urgent Care or the Emergency Room except in the case of a true emergency.
Do you agree with our use of Urgent Care policy?* (required) Late Policy Everyone’s time is precious. Our providers work very hard to see each patient as efficiently as possible in order to reduce wait times. When your family runs late, this often means another family (or 2!) later in the day has to wait longer for their scheduled appointment. We request that you arrive 10 min prior to every appointment in order to fill out paperwork. In order to be fair to every family we care for, if you are more than 10 minutes late for your appointment, you will be asked to reschedule.
Do you agree with our "late policy"?* (required) NO SHOW POLICY : A t TLC Pediatrics, we value your time and strive to provide timely care for all our patients. Missed appointments or late cancellations prevent other families from accessing needed care. Patients with commercial insurance who do not show for a scheduled appointment or fail to cancel at least 24 hours in advance will be charged a $50 no-show fee . Patients with state insurance ( Husky/Medicaid) who miss three appointments without proper notice may be discharged from the practice .
Do you agree with our "no show" policy?* (required) Continuity of Care: We believe that the best quality of care is provided when patients see one specific provider for all of their routine needs such as physicals and consults. That said, our providers practice as a team. For same-day sick visits, you will be scheduled with the next available provider. .
Do you agree with our "continuity of care" policy?* (required) Payments due at time of service All copays are due at the time of service. As a courtesy, a credit or debit card will be kept securely on file to take care of copays, deductibles, or any outstanding balances. We will always notify you before any charges are made”.
Do you agree to our payment policy?* (required) Billing Insurance: Your insurance will be charged for your visit. We follow evidence based medicine and the recommendations of the American Academy of Pediatrics and cannot tailor our medical workup to work within the confines of what your insurance will cover. We will, however, make every reasonable effort to prescribe your insurance’s preferred medications, when medically indicated. We will bill your insurance for all of the services provided at a given visit, and once the explanation of benefits is received, we will charge the patient’s portion (deductible, co-insurance, etc.) to the credit card on file.
Do you agree with our billing insurance policy?* (required) Billing during physical exams : Insurances are required to cover well visits for children. If, however, any additional concerns arise during the course of the physical exam, this may generate additional codes, and you may be responsible for a co-pay or portion of your deductible for this visit.
Do you agree with our billing policy during physical exams?* (required) Permission to Treat: I give TLC Pediatrics authorization to provide reasonable medical care for my child or children, in accordance with the standard of practice in today’s era.
Acknowledgement of the Above Policies: I have read and understand the above policies, and agree to adhere to them. I give TLC Pediatrics permission to treat my child or children.
Parent or Guardian Name#1* (required) Parent or Guardian Name#2 Name and number of your health insurance carrier (if your child is a newborn and you don't have insurance information yet, please let us know below)* (required) Name of Policy Holder* (required) Date of Birth of Policy Holder* (required) Signature of Parent or Guardian* (required) Signature of Parent or Guardian
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