Established Patients Over 18 Packet

  • Glendale Pediatrics

    18 years and older Demographics
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Contact Information

    (Please list numbers in order of preference)
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.

  • Primary Insurance Information:

  • Secondary Insurance Information

  • I hereby assign my insurance benefits to be paid directly to Glendale Pediatrics, A Professional Corporation. I am responsible for informing Glendale Pediatrics of any specific laboratory, radiology and other ancillary services that my insurance company is contracted with. I am financially responsible for non-covered services, co-pays and deductibles. I authorize Glendale Pediatrics, A Professional Corporation, to release to my insurance carriers any information required to process my child(ren)'s claims.

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  • PATIENT INFORMATION COMMUNICATION CONSENT FORM

    Please initial all that apply

  • Ok to disclose information about my medical care or treatment to any individual who states they are a family member or friend.

  • Ok to disclose information about my medical care or treatment to only the following family members or friends (check all that apply):

  • Parent/Legal Guardian 1 (Name)          

  • Parent/Legal Guardian 2 (Name)         

  • Stepparent 1 (Name)         

  • Stepparent 2 (Name)         

  • Other          

  • Do not disclose information about my care or treatment to any individual, regardless of the relationship.

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  • OFFICE PROCEDURE, FINANCIAL POLICIES, PAYMENT FOR SERVICES ACKNOWLEDGEMENT PAGE

    18+ years of age

  • CANCELLATION POLICY

    A specific time is reserved for you when you schedule an appointment. If you cannot keep your scheduled appointment, please give us at least 24 hours notice so that we may reschedule the appointment and offer the reserved time to another patient. It is our policy to charge $75 for appointments that have been scheduled in advance and are canceled/missed with less than 24 hours notice. Please be aware that this applies to same-day appointments as well; however, if your appointment is booked and canceled within one hour, there will not be a cancellation fee.

    UNSCHEDULED APPOINTMENTS

    Appointments requested in the office without prior arrangement will be made according to our discretion with consideration given to other patients' scheduled appointments. Any unscheduled patient who requests that one of our physicians work them into their schedule will be charged a work-in fee of $50. This fee is not covered by insurance and is due at the time of service.

    ADDITIONAL HEALTH ISSUES ADDRESSED DURING PREVENTIVE CARE APPOINTMENTS

    Preventive Care is an important part of healthcare. If, during an annual physical well visit, your child is sick or has an issue that is not related to the routine health maintenance and development of your child that needs treatment and/or medical attention/guidance for your concerns, your provider may bill the insurance company for both services. Your insurance benefits may require that you pay a co-pay, co-insurance and/or may apply the visit to your deductible. Please note that medical questions regarding an unscheduled sibling will be billed as an office visit.

    SATURDAY APPOINTMENTS

    We offer Saturday morning appointments for urgent visits. While we are happy to offer this appointment-only service, please be aware that there is an additional $60 fee for weekend appointments.

    CREDIT CARD POLICY

    At check-in, your credit card information will be obtained and stored securely. In the event that your authorized card changes or is declined, you agree to immediately notify Glendale Pediatrics and provide us with a new, valid credit card which will be used to charge any payments as described above.

    A $35 fee will be charged if your credit card payment is declined for any reason. Please make sure that the card information you give us is accurate and that your credit card on file remains valid at all times.

    Cash patients will need to pay in full at the time of service. For your convenience, we accept cash, checks, MasterCard, Visa, American Express, and Discovery Card. There is a $35 charge for all returned checks.

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  • 2025 Financial Policy Acknowledgment form 12/2024

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