Thank you for considering Home Sweet Home Pediatrics for your child’s healthcare. Our goal is to provide high-quality, evidence-based healthcare from the comfort of your home. We strive to maintain excellent and transparent communication with our parents/guardians and in keeping in alignment with that objective, we would like you to be aware of our practice policies.  

We reserve the right to make changes to our Policies Agreement at any time and to make such changes effective for all of our patients and staff. If these conditions change, Home Sweet Home Pediatrics will provide you with a copy of the Policies Agreement upon your request. 

These conditions are important, evidenced-based recommendations that are intended to prevent harm and optimize the safety, growth, and development of your child. These conditions cannot be altered and must be met to enroll and continue as patients of Home Sweet Home Pediatrics.

Newborn Screens: Newborn screens are vital to the health and well-being of infants. Arizona newborn screens test for several hematologic, metabolic, and endocrine disorders that if not detected soon after birth, may cause harm to your child. Early detection and prompt intervention can prevent serious, life-long disability or death. Two newborn screens must be completed and sent to the Arizona Department of Health Services. The blood sample (heel stick) for the first newborn screen is typically obtained at 24 hours of life and the second blood sample between 5 and 10 days of life. Newborn screens sent to out-of-state or private laboratories will not be accepted as replacements for the two required Arizona newborn screens as this may lead to a delay in illness detection. 

Newborn Hearing Screen: All newborns should have a hearing screen shortly after birth. Most hospitals will provide a hearing screen called an auditory brainstem response (ABR) to test the neurologic component of hearing (the auditory nerve). Otoacoustic emissions testing (OAE) is another hearing screen that can be performed after birth, although this test is less sensitive and specific than an ABR. If an ABR cannot be obtained because of birth location or limitations in equipment (birth center or home birth), an OAE is an acceptable alternative. A hearing screen must be completed for all newborns regardless of birth location.

Intentionally Unassisted Homebirths: Home Sweet Home Pediatrics is not currently accepting infants less than three months of age born during intentionally unassisted homebirths. Intentionally unassisted homebirths are planned homebirths in which the family has decided not to have a midwife or physician present during labor and delivery. This does not include accidental/unintentional homebirths in which the infant received prompt medical evaluation after birth. Unassisted homebirths and lack of medical/professional oversight can result in failure to detect problems during labor and delivery, such as bleeding, fetal distress, or breech positioning. Please note: Two Arizona state newborn screens are required as a condition of enrollment.

I understand Home Sweet Home Pediatrics does not currently offer in-home vaccination services. Parents/guardians who wish to have their children vaccinated will be provided with a vaccine schedule, a list of vaccines due for their child’s age, locations where vaccines can easily be obtained and insurance accepted, and counseling related to specific vaccines and potential side effect management.

Vaccines are extremely effective at preventing the spread of harmful communicable diseases. Vaccines undergo extensive clinical trials to test safety and efficacy. Home Sweet Home Pediatrics endorses the Centers for Disease Control and Prevention Birth – 18 Years Immunization Schedule. While children are not required to be vaccinated as patients of Home Sweet Home Pediatrics, the opportunity to discuss vaccines and ask/answer questions will be provided at every wellness visit as recommended by the American Academy of Pediatrics. Vaccine-related discussions are meant to be educational and provide clarification in a non-judgmental, respectful, and collaborative manner.

I understand that some vaccine-preventable diseases are common in other countries and an unvaccinated child could easily get one of these diseases while traveling or from a traveler.

I understand that if my child does not receive vaccine(s) according to the medically recommended schedule, the consequences may include contracting the illness the vaccine is designed to prevent. The outcomes of these illnesses may include one or more of the following: Certain types of cancer, pneumonia, illness requiring hospitalization, death, brain damage, paralysis, meningitis, seizures, and deafness; other severe and permanent effects from these vaccine-preventable diseases are possible as well.

I understand that not vaccinating increases the risk of transmitting vaccine-preventable diseases to others (including those too young to be vaccinated or those with immune problems), which may require my child to stay out of childcare or school and require someone to miss work to stay home with my child during disease outbreaks. My child’s provider and the American Academy of Pediatrics, the American Academy of Family Physicians, and the Centers for Disease Control and Prevention all strongly recommend that vaccine(s) be given according to recommendations.

I understand I will be given the opportunity to read each Vaccine Information Statement from the Centers for Disease Control and Prevention explaining the vaccine(s) and the disease(s) it prevents for each of the vaccine(s) due for my child’s age. I understand that I will be given the opportunity to discuss medically recommended vaccines, any concerns, and the risks of not vaccinating with my provider. I understand that all of my questions about the recommended vaccine(s) will be answered. I understand that a list of reasons for vaccinating, possible health consequences of non-vaccination, and possible side effects of each vaccine is available at www.cdc.gov/vaccines/pubs/vis/default.htm.

I understand the intended purpose of and the need for medically recommended vaccine(s). I understand the risks and benefits of medically recommended vaccine(s). I understand that Home Sweet Home Pediatrics is not liable for any costs, illnesses, hospitalizations, harm, or death that may result from contracting a vaccine-preventable disease.

Home Sweet Home Pediatrics’ services, including home visits, telehealth visits, phone consultations, and messaging your provider are not intended for use in the event of an emergency or when a patient needs urgent care and cannot safely wait to be examined by a healthcare provider. For all urgent or emergent needs that you believe may immediately affect your child’s health, you must immediately go to the nearest emergency room or call 911 if necessary.

For all patient visits (in-person and telehealth) the patient must be in the home and available for physical/virtual exam for the duration of the appointment.

The parent, guardian, or designated individual (who must be listed in the Consent from Parents or Guardians for Authorized Persons) must be present for the duration of the telehealth and/or home visit.

Patients must maintain up-to-date wellness exams as recommended by the American Academy of Pediatrics including the newborn visit, 1-month, 2-month, 4-month, 6-month, 9-month, 12-month, 15-month, 18-month, 2-year, 2.5-year, 3-year, and annual wellness visits after three years of age to ensure adequate clinical supervision of growth, development, and safety.

Adolescent and teenage visits, when appropriate, will likely include discussions regarding high-risk behavior, sexuality, peer pressure, school-related issues, and depression.

Parents/guardians are expected to send non-urgent messages/questions/updates on their child’s condition through the patient portal. Utilizing the patient portal for all non-urgent needs is important for keeping up-to-date records regarding your child’s health. You can expect a reply within 48-72 hours.

Parents/guardians will be provided with a phone number that can be used to communicate with their provider for urgent issues only. You can expect a reply to urgent needs/concerns within 24 hours. Voicemail messages will be responded to based on patient need/urgency. Less urgent messages may take up to 24 hours to respond to. For all urgent or emergent needs that you believe may immediately affect your child’s health, you must immediately go to the nearest emergency room or call 911 if necessary.

Divorced/Separated Parents or Guardians: Home Sweet Home Pediatrics does not become involved in legal/custody issues with parents/guardians. Unless there is a court order in the child’s record that restricts a parent’s/guardian’s rights, the practice will not limit the other parent’s/guardian’s involvement in the child’s care or communication with their provider. Special requests for non-court ordered activities will not be accepted.

The most up-to-date pricing for all visits and additional services is available for review on the Home Sweet Home website at http://homesweethomepediatrics.com. The pricing listed on the website on the day of the visit will be the price charged for the visit and any additional services rendered.

Home Sweet Home Pediatrics reserves the right to adjust (increase or decrease) the pricing for any offered services at any point and will inform patients (by email) of any fee changes within 30 days of fee adjustment becoming effective.

Payment for the visit and any additional services, as well as any prior balances, is due at the end of the visit. There may be circumstances that require payment through the patient portal. In the event payment cannot be made at the end of the visit, full payment for the visit is expected within 24 hours of the scheduled visit time.

You may use cash, any major credit card (Visa, Mastercard, American Express, and Discover), debit card, the patient portal (only if payment cannot be made at the end of the visit), or a Healthcare Savings Account (HSA) card to make payment at the end of the visit. Should you attempt to use an HSA card and the payment is not approved, you will be responsible for provision of an alternate credit card for payment.

Point-of-care testing (such as Rapid Strep or Rapid COVID testing) and “additional services” (listed on the Home Sweet Home website) are offered at an additional cost and are not included in the cost of newborn, wellness, or sick visits.

Any outstanding account balances that are not paid within 60 days of the visit may be sent to collections.

For membership patients/families, the monthly membership fee will be due at the first visit (in-home or telehealth). Parents/guardians are expected to keep an up to date payment source with the membership billing service, Hint Health. Payments will automatically deduct each month on the designated date.

Membership requires a six month commitment. Parents/guardians who cancel membership prior to the end of the first six months will be responsible for paying membership fees for any remaining months that fall within the first six months of membership. After six months, parents/guardians are required to provide a 30 day notice to cancel membership. Parents/guardians will be responsible for any payments due within the 30 day cancellation window.

Home Sweet Home Pediatrics CANNOT accept cash payment for services from patients who are enrolled in AHCCCS, including patients who use AHCCCS as secondary insurance. By signing this document, you confirm your child is not currently enrolled in AHCCCS. You understand that if your child enrolls in AHCCCS in the future, it is your responsibility to notify Home Sweet Home Pediatrics immediately to initiate transfer of care to an AHCCCS enrolled provider.

I understand, acknowledge, and accept all of the above terms and conditions as stated under the Newborn, Vaccinations, Visit Requirements, Provider Communication, and Pricing and Payments, and Arizona Health Care Cost Containment System (AHCCCS) - Arizona's Medicaid Agency subheadings, located within the Conditions for Initial and Continued Patient Enrollment Acknowledgment. 

I request release of my child’s health information FROM:

The health information to be used/disclosed includes: (check all that apply)

I hereby request and consent that my medical records and non-written records be sent to my referring providers, those providers or ancillary facilities that I am referred to by Home Sweet Home Pediatrics and to my insurance company or its agents that may be authorizing treatment. I further understand that I do not have to sign this authorization in order to get health care benefits. I understand that I may revoke this authorization in writing at any time except to the extent that Home Sweet Home Pediatrics has acted in reliance upon this authorization. Once this office discloses health information, the person or organization that receives it may re-disclose it (dependent on their policy) and Home Sweet Home Pediatrics does not take responsibility for the protection of this information. 

You agree that you will disclose a full and accurate family history and medical history, including any and all information regarding the child’s medical conditions, special medical needs, hospitalizations, surgeries, medications, vitamins, and herbal supplements. You understand that failure to do so may affect the treatment outcome and increase the likelihood or severity of complications.

You give permission for the administration of medication to the child if needed as part of the care and treatment we provide.

You understand that you are liable for all charges for and related to “care services” including third party expenses such as, without limitation, labs, diagnostics, testing, imaging, and other products and services.

You understand that no information regarding services performed shall be released without your express consent except as follows: You authorize that copies of your child’s records may be sent to another location if you/the child seek additional treatment at that location. You understand that, in addition to authorized Home Sweet Home Pediatrics personnel, other organizational staff and consulting providers shall have full access to the child’s medical records. You understand that appropriate medical review may be conducted to further the safety and efficacy of the provider’s services.

You understand that photographs may be taken to document treatment results, but they will not be released or used otherwise without your specific written consent.

Your provider will maintain file copies of all records for a minimum of three years.

The Home Sweet Home Pediatrics’ providers shall provide the care and treatment services described herein (“Care Services”) according to professional standards. Home Sweet Home Pediatrics shall have no duty to provide or accept responsibility for services or care outside the parameters of this Agreement.

You understand that even proper treatment administered in a proper manner may still have certain risks. You agree that the medical care offered and provided has been explained to your satisfaction with your questions answered to your satisfaction.

By your signature below you acknowledge that Home Sweet Home Pediatrics has fully and fairly disclosed and explained the Care Services and that your questions have been answered, each to your satisfaction.

PLEASE CAREFULLY READ THE FOLLOWING AND INITIAL IF APPLICABLE:

I am granting full permissions, meaning the below listed person(s) will be allowed to agree to treatments, and know all health history pertaining to my child.

If you do not authorize any other person aside from you, the biological parent/legal guardian, to be present with your child for any appointment and agree to treatment and health history of your child, please do not complete this section. Please be advised if any other person other than you, the biological parent/legal guardian is present with the patient at any appointment without written consent, the patient will not be seen. THIS INCLUDES STEP-PARENTS, GRANDPARENTS, ETC. Your provider will not be permitted to obtain any other type of consent, such as verbal consent, from anyone including the biological parent/legal guardian. 

Please list person(s) here:

I understand that as part of my child/children's health care Home Sweet Home Pediatrics originates and maintains health records. These records describe history, symptoms, examination and test results, medical diagnoses, treatments, and any plans for future care or treatment. I also give consent for my child/children to receive medical evaluation and treatment by any provider with Home Sweet Home Pediatrics, PLLC. I acknowledge that the Notice of Privacy Practices, which describes uses and disclosures of my child's/children’s protected health information, have been made available to me. I am granting authority to download my child’s/children’s medication history automatically from pharmacy benefit managers (PBMs) or any other entity that maintains medication history for my child/children.

I acknowledge the above information to be true and complete. I understand that I will have to provide a state issued identification card or driver’s license for proof of identification at my child’s first visit. I will upload a copy of my state issued identification card or driver’s license in the patient portal immediately following my child’s first visit. Failure to provide a copy of my state issued identification card or driver’s license at my child’s first visit will result in rescheduling.