Patient Registration 2025

RTC Pediatrics, a division of Trusted Doctors, LLC

Patient Registration, and Insurance Information
We will contact you within 3–5 business days to let you know what the next steps are before scheduling appointments.

Important Reminders

After the birth of your new baby, be sure to fill out the necessary paperwork to add your baby to your insurance policy. Most insurance companies allow 30 days from the date of your child’s birth to send in the paperwork. If you miss the deadline, claims filed on behalf of your newest family member will be denied, and you will have to wait until your next open enrollment period to add him or her to your policy.

For annual physical exams, many insurance companies do not cover two physicals within a one-year period. Please check with your insurance company to verify coverage for physicals if you have questions.

In addition, the wellness visit covers preventive care only. It does not cover sick visits (e.g., fever, cough, ear infections), chronic disease management (e.g., asthma, ADHD follow-ups), in-depth evaluations for new concerns (e.g., behavioral issues, unexplained symptoms), or procedures or lab work beyond routine screenings. If additional concerns or medical issues are discussed during the visit, insurance may process them as a separate service, which could result in an additional charge.

All patients are responsible for presenting their current primary and (if applicable) secondary insurance cards at every visit. Co-pays are due at the time of service. If you do not have evidence of current insurance with one of our doctors as primary care provider, or if your child is not covered under any insurance, you will be required to pay in full for services at the time of your visit. Patients will be required to complete a new Patient Registration form each year, and whenever their demographic and/or insurance information has changed.

New Patients

To establish ongoing care with Reston Town Center Pediatrics, please complete the form below along with the age-appropriate New Patient Questionnaire(s) and Credit Card on File consent forms.
Newborn appointments will be scheduled within 24–48 hours after your discharge from the hospital. For babies 0–4 months old, we reserve weekly appointments for well visits—call our office to schedule. For children over 4 months, call to check availability, as appointments are scheduled out 4 months in advance.
For older patients, we will contact you within 3–5 business days to schedule your first visit.
Please arrive 15 minutes before your first appointment to complete any remaining paperwork and securely save your credit card information at the Front Desk.
We will need the following patient records before your first RTC Pediatrics appointment, so please reach out to your previous pediatric office right away to request the records listed below if you do not already have this medical history on hand:
- Immunization records
- Growth charts
- Provider's notes from last well visit
- If patient has seen specialists or is on medication(s), then additional records are requested
At RTC Pediatrics, we believe that all children should receive recommended vaccines according to the schedule from the American Academy of Pediatrics (AAP). Vaccines are a safe and effective way to protect your child from serious illnesses and help keep our community healthy.

To support your child’s health and the safety of all our patients, families, and staff, we ask that children begin their vaccines by 4 months of age and stay up to date at important milestones—2 years, 5 years, 12 years, and 17 years.

We understand that families may have questions, and we are always happy to talk through any concerns with you at your child’s visit.
Family newly joining RTC PediatricsOne or more children already established here and adding additional sibling(s)Returning to practice after several years
Please provide any additional information about your care needs at this time:
Please enter ALL PATIENTS in your family:
YESNO
Home Address:*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Parent/Guardian #1 (Responsible Party for Billing Statements) *

First NameLast Name
Date of Birth*

MonthDayYear
Date
FemaleMale
Primary Language:
Relationship to Patient(s): *
Cell Phone: *
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Email: *
example@example.com
Employer:
Address is the same
Address, if different from child(ren)'s:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #2:

First NameLast Name
Date of Birth: *

MonthDayYear
Date
FemaleMale
Primary Language:
Relationship to Patient(s): *
Cell Phone: *
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Email: *
example@example.com
Employer:
Address is the same
Home Address, if different than child(ren)'s:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Insurance Policy
Full Name of Insurance Policy: *
Member ID # (including letters, if applicable) *
Group # (including letters, if applicable)*
Address Listed ON Insurance Card:

PO Box

CityState / Province

Postal / Zip Code
Insurance Company Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Subscriber's Name: *

First NameLast Name
Subscriber's Date of Birth: *

MonthDayYear
Date
Subscriber's Relationship to Patient: *
Please upload digital image of the FRONT + BACK of Primary Insurance Card:

Cancelof
Alternatively, please take a clear photo of the FRONT of your Primary Insurance Card:
And a clear photo of the BACK of your Primary Insurance Card:
Secondary Insurance Policy (if applicable)
Full Name of Secondary Insurance Policy:
Member ID # (including letters, if applicable)
Group # (including letters, if applicable)
Address Listed ON Insurance Card:

PO Box

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Insurance Company Phone #:
Please enter a valid phone number.Format: (000) 000-0000.
Subscriber's Name:

First NameLast Name
Subscriber's Date of Birth:

MonthDayYear
Date
Subscriber's Relationship to Patient:
Please upload digital image of the FRONT + BACK of Secondary Insurance Card:

Cancelof
Alternatively, please take a clear photo of the FRONT of your Secondary Insurance Card:
And a clear photo of the BACK of your Secondary Insurance Card:
Provide up to two emergency contacts: (other than guardians previously listed)
Name:*

First NameLast Name
Relationship: *
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Name:

First NameLast Name
Relationship:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Other than parents/legal guardians, I authorize the following persons to bring my child to be seen and treated at RTC Pediatrics (optional to add)
Name:

First NameLast Name
Relationship:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Name:

First NameLast Name
Relationship:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Signature of Parent/Guardian or 18+ year old Patient: *
Today's Date: *

MonthDayYear
Date
Patient Conduct and Dismissal Policy

Purpose: RTC Peds is committed to providing a safe, respectful, and professional environment for patients, families, and staff. This policy outlines expectations for behavior and the circumstances under which a patient may be dismissed from the practice.
Expected Conduct
All patients, parents, and guardians are expected to communicate respectfully with providers, staff, and other patients. We recognize that medical situations can be stressful; however, respectful communication must be maintained at all times.

Unacceptable Behavior
The following behaviors are not tolerated and may result in dismissal from the practice:
• Verbal abuse, including yelling, profanity, insults, or derogatory language directed at staff or providers.
• Threatening language or behavior, including implied or explicit threats toward staff, providers, or the practice.
• Harassment, intimidation, or discriminatory remarks.
• Repeated disruptive behavior that interferes with clinic operations or patient care.
• Aggressive actions such as slamming phones, refusing to de-escalate when asked, or hostile confrontations in person or via phone/electronic communication.
• Threats of public defamation or retaliation directed at staff or providers.

Response to Concerning Behavior
Depending on the severity and frequency of the behavior, RTC Peds may take the following steps:

1. Verbal Warning – The individual will be informed that the behavior is inappropriate and must stop.
2. Written Warning – Documentation of the behavior and expectation for immediate improvement.
3. Immediate Dismissal – In cases of severe or threatening behavior, the practice reserves the right to dismiss a patient without prior warning.

Dismissal Process
If dismissal is deemed necessary:
• The patient/guardian will receive written notice of termination of care.
• The practice will continue to provide urgent care only for 30 days from the date of the notice to allow time to establish care elsewhere.
• Assistance will be provided to transfer medical records upon receipt of appropriate
authorization.
• Patients will be advised to seek a new provider, typically through their health insurance network.

Emergency Care
Dismissal from the practice does not apply in emergency situations. Patients should seek emergency care by calling 911 or going to the nearest emergency department.

Non-Discrimination
Dismissal decisions are based solely on behavior and not on race, ethnicity, gender, socioeconomic status, or any protected characteristic.

Commitment to Care
RTC Peds remains committed to providing compassionate, equitable, and high-quality care. This policy exists to ensure that such care can be delivered in a safe and respectful environment for all.
Should be Empty:

RTC Pediatrics, a division of Trusted Doctors, LLC

Please enter ALL PATIENTS in your family:

Primary Insurance Policy

Secondary Insurance Policy (if applicable)

Provide up to two emergency contacts: (other than guardians previously listed)

Other than parents/legal guardians, I authorize the following persons to bring my child to be seen and treated at RTC Pediatrics (optional to add)

Patient Conduct and Dismissal Policy