TV Kids Clinic Registration

Welcome!

We are excited to have your family join us. Please review our policies, complete the registration and sign up for Quick Pay!
Insurance Carrier(s)*
Please verify with your insurance company that we are in-network prior to your first appointment
Other (please specify)
We are attempting to contract and credential with all major insurers. Please contact us if your insurer is not listed above.

Clinic Policies

We know everyone hates rules--especially toddlers and teens! Our goal is to build a long-lasting relationship with your family, and understanding our policies is key to setting appropriate expectations and ensuring a smooth experience for all.
Key Policy Reminders

Our goal is to build a partnership with our patients in their care. In order to do so we simply ask that you abide by three simple rules:

1. Be courteous and respectful to each other and our staff. We have a zero-tolerance policy for misbehavior and abuse.
2. Be on time and ready for your appointment. We understand that emergencies arise (both on your part as well as ours). Please cancel any appointment you cannot make at least 24 hours in advance.
3. Be vaccinated. We follow the AAP Bright Futures and ACME vaccination schedule. We strive to help educate and overcome any vaccine hesitancy. While we do not mandate the flu, COVID-19 and HPV vaccines, we highly encourage our patients getting them. We only allow for alternative or customized vaccine schedules on a case by case basis after discussion with a provider. We require patients who transfer into our practice and are behind on their vaccine schedule to agree to a catch-up schedule to become patients with us.
Please review the attached policies and acknowledge below (a copy of this will be emailed to you following submission)

Primary Care Provider Preference

We are excited to have an excellent team to help care for your family. All providers are excellently trained and follow the same philosophy and standards of care. Some patients/families may prefer a specific gender for their PCP. As best as able we aim to accommodate your choice below.
PCP Gender Preference*

MaleFemaleNo Preference

Medical Issues and Concerns

In order to provide the best care, please list below any chronic medical conditions (i.e. medical issues that require ongoing medications or visits to specialists) and/or significant concerns (i.e. growth and development, behavior, etc.).

Parent or Guardian Information

Parent/Guardian #1
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Hey there! Can you give us your cell phone number so we can keep you in the loop with important office updates and appointment reminders? It'll make things a lot easier for everyone!
Email Address (for patient portal)*
example@example.com
Parent's Preferred Language*
Relationship to Child*

MotherFatherStepmotherStepfatherGrandmotherGrandfatherOther

Parent or Guardian Information (Optional)

Parent/Guardian #2
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Hey there! Can you give us your cell phone number so we can keep you in the loop with important office updates and appointment reminders? It'll make things a lot easier for everyone!
Email Address (for patient portal account)
example@example.com
Parent #2 Preferred Language
Relationship to Child

MotherFatherStepmotherStepfatherGrandmotherGrandfatherOther

Insurance Information
Name of Subscriber*

First NameLast Name
Insurance Company Name (as it appears on your card)*
For Medicaid:
Medicaid ID #
Insurance ID (or certificate) #
Group #
Co-Pay Amount Listed on Card:
Date of Birth (of subscriber)

MonthDayYear
Date
Employer
Insurance Card (front and back)

Cancelof
Camera Photo

Treasure Valley Children's Clinic Quick Pay

with Credit Card on File Authorization
QuickPay FAQ: Making Payments of your Personal Balance Effortless
QuickPay is our new credit card on file program that is here to save you time, reduce stress, and make your life easier!

Why QuickPay?
Convenience for Families: Simplify your payment process—no mailed statements, checks or extra trips to the post office!
Go Green: Help reduce paper and postage waste by switching to electronic statements.
Avoid Late Fees: Stay on top of payments effortlessly and stress-free.

Who is QuickPay For?
QuickPay enrollment is for everyone to ensure a smooth payment process

Easy Enrollment:
Easily enroll by supplying your credit card or Health Savings Account (HSA) card below. Alternatively you can elect to provide your credit card or HSA card information at your child's first appointment during check-in.

Monthly Notifications:
An electronic notification is sent between the 1st and 8th of each month for anyone with an outstanding personal balance greater than $5
Prefer a different payment method? Just let us know and we can change your payment preference or set up a payment plan if needed.

Effortless Payments:
Your credit card or HSA card is charged approximately 7-10 days after notification, ensuring payments are handled on time with no hassle.
CREDIT CARD AUTHORIZATION

I authorize Treasure Valley Children's Clinic to charge my unpaid personal bill as described within the clinic's financial policy above.

This authorization will remain in force on each of my children’s accounts until
they are no longer patients of Treasure Valley Children's Clinic and any outstanding balances are paid or until a written request by the cardholder instructing the practice to remove the authorization.
Signature

Clear

Treasure Valley Children's Clinic Quick Pay

USDEnter 0.01 (this is required to process your credit card on file)

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Please verify that you are human, if you do not enter credit card information you will still need select this!

And lastly...
How did you hear about us?*
Should be Empty:

Welcome!

Clinic Policies

Clinic Registration

Primary Care Provider Preference

Medical Issues and Concerns

Parent or Guardian Information

Parent or Guardian Information (Optional)

Insurance Information

Treasure Valley Children's Clinic Quick Pay

And lastly...