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 

 

RTCP Financial and HIPAA Agreements

Understanding Insurance Information & Terminology 

Deductible: an amount that must be paid out of pocket before the insurance company will pay any expenses.

Coinsurance: the percentage you are required to pay (after the co-pay and deductible) of the allowed amount for a service.

“Birthday Rule”: Insurance companies follow what is called the “birthday rule” if a patient has more than one insurance. This means the primary policy is held by the person with the birthday month that falls first in the year. This excludes Medical Assistance and Tricare, which always default to secondary insurance. 

It is very important that the primary care physician is one of our doctors and the insurance lists Trusted Doctors as your primary care facility. If it does not, you could have a higher co-pay, or your claims might not be paid. RTC Pediatrics cannot update this for you.

Some insurance companies require accident details to process a claim. This is most likely a form that is to be filled out and sent back to them. 
 
Billing & Insurance 
 
Health insurance is important to all of us, but it can be difficult to understand. The benefits, rules, and restrictions are determined by the terms of your policy, as well as the contracts RTC Pediatrics has with various insurance carriers. Please remember that your insurance policy is a contract between you and your insurance company. Although we accept many different insurance plans, coverage varies from plan to plan, and our billing department may not know the exact details of your coverage. If you feel that you were billed for services that should have been covered by your insurance, you should first contact your insurance company. 

A notice to our patients and families: Starting February 3, 2025, RTC Pediatrics billing invoices will now come from Trusted Doctors, for dates of service starting on 2/1/2025. Dates of service prior to 2/1/2025 will come from RTC Peds. Potentially you could receive two statements, both balances are valid.  

 Payments & Fees: 

Patient balances are due within 30 days after insurance pays. If your insurance plan is subject to routine deductibles and coinsurance, we require you to keep a credit card on file so we can collect those charges as soon as your insurance carrier designates your financial responsibility for the claim. We will only charge your credit card without prior notice if the claim was adjudicated normally. If your credit card on file expires or otherwise becomes uncollectable, we will expect you to promptly provide a new means of payment. Please complete our Credit Card on File Authorization Form and then visit the Front Desk to securely swipe and save your credit card information into our system.  

If charges remain unpaid after 30 days, a second statement will be rendered with a notice requesting immediate payment. When your account is not paid in a timely manner, your child may be turned away for non-emergent services until the balance is paid.  

If the balance remains unpaid, your account will be referred to a collection agency. You are responsible for any collection costs as well as attorney fees associated with collection in addition to your outstanding bill.  

If you are referred to collections, you will be given a 30-day notice of discharge from our office, which means you will need to find a different pediatrician for your child.  

Please understand that if you include debt owed to us in a bankruptcy filing, your account will be closed, and you will be given a 30-day notice of discharge. We much prefer to work out acceptable payment arrangements and continue to provide care for your child, so please talk to us before filing. 

Missed Appointments, Administrative & Additional Fees: 

We understand that there are occasional circumstances that may keep you from the appointment. When this happens, we request 24 hours advance notice for physical exams, consultations, behavioral health visits, and medication checks, and 2 hours advance notice for sick visits. We charge a fee when you fail to notify us of a cancelled appointment, or if you do not arrive within 15 minutes of a scheduled appointment.  

This charge is not covered by insurance and is your responsibility. We may provide a reminder for appointments; this is a courtesy only and has no effect on your financial obligation for a missed appointment. 

• It is our policy to charge $25 (or $50 during June–August) for an office sick visit that is missed without 2 hours' notice.
• The no-show fee for physicals, consults, behavioral health, and other specialty appointments is $50 (or $100 during June–August).

Uncovered Services 

This section fulfills any prior notification requirement your insurance carrier may require contractually of our practice regarding any and all uncovered services. Please read this section carefully.  

Each health care plan and insurance policy have services that it specifically excludes. Some examples are standard of care or screening tools recommended by the American Academy of Pediatrics (MCHAT, EPDS, and PSC-17), Fluoride Varnish, and Spot Vision screening.  

Please be aware that we are required to report visits outside of normal business hours to your insurance provider; these are assigned an Extended Hours Fee (CPT 99051). Appointments scheduled before 8am, after 5pm, or on Saturdays and on federal holidays will incur this fee, which may be applied to your co-pay, coinsurance, or annual deductible. Some insurance plans do not cover this fee. 

There is often no consistency in these rules, and each patient/family must read the details of their own policy. By requesting or receiving a service, a patient (and guarantor) agrees to be personally responsible for payment of uncovered services. Uncovered services are to be immediately paid for in full and will not be waived. 

School, Sports, Camp, & Daycare Forms 

Because of the increasing demand, complexity, and length of time it takes to complete school, sports, camp, and daycare forms, it is very important that you bring your form to us as soon as it is received. Parents should complete their portion of the form in advance. Most forms can be found directly at RTCPeds School and Sports forms. 

The standard processing fee for a form is $20; you can expect these forms to be completed within 7–10 business days. The fee for rush processing of a form (24–48 hours) is $45. Forms requested during a well check do not incur fees.

Divorce & Separation Decrees 

RTC Pediatrics is not a party in divorce or separation decrees or in child support arrangements. We bill one guarantor, at one address, and expect prompt payment. We do not handle billing or insurance coverage disputes between parents. 
 
After-hours Triage Calls 

After regular office hours, our on-call triage service will help you in a medical emergency. When you call the office number, you will get transferred to our triage service, and your call will be promptly returned. The triage service always has access to one of our physicians. You may incur a $25 fee for this service.  

Medical Records 

In the state of Virginia, the physician who creates the patient’s medical records is the owner of the records and is permitted to charge a processing fee. RTC Pediatrics charges a standard processing fee of $20 per child per copy. Rush processing fees are $45. This fee must be received before records are released to you or your child’s new physician. Upon receipt of fee, requests for release of medical records will take up to 14 business days to process. There is no fee for request of immunization records. Any medical records for a patient 18 years and over must be requested by the patient. Please complete the Authorization for Medical Release form. 

This form may also be used by patients transferring into our practice to request medical records from their previous physician. 

 Acknowledgement of Financial Policy  

Acknowledgment of HIPAA Policy Patient Consent

I understand that the patient's Protected Health Information (PHI) is private and confidential. I understand that RTC Pediatrics works very hard to protect the patient's privacy and preserve the confidentiality of the patient's personal health information. I hereby give my consent to Reston Town Center Pediatrics to use and disclose PHI about me/my child to carry out treatment, payment, and health care operations. RTC Pediatrics’ Notice of Privacy Practices provides a more complete description of such uses and disclosures. I understand that I have the right to read the Notice of Privacy Practices before signing this Acknowledgment. The Notice of Privacy Practices may be updated periodically. 

A copy of the Notice of Privacy Practices may be obtained at our Front Desk or through our website.  

By signing this form, I acknowledge receipt of the office’s Notice of Privacy Practices. I also consent to allowing RTC Pediatrics to call, email, fax, or mail my home or any other alternative contact point I provide. RTC Pediatrics may leave a message on voicemail or communicate in person or in writing regarding any items that may assist the Practice in carrying out treatment, payment, or healthcare operations, such as appointment reminders, insurance issues, and clinical care (including testing results). I understand that I have the right to request that RTC Pediatrics restricts how it uses or discloses my PHI to carry out treatment, payment, and healthcare operations. The practice does not have to agree to my requested restrictions, but if it does, it is bound by the agreement. All requests for restrictions must be submitted in writing. 

If I choose to add any additional names to the bottom of this form, I agree that they are allowed to receive PHI in the same manner as described above (with the exception of information relating to STD/STIs, HIV/AIDS, pregnancy testing, and records relating to drug, alcohol, or mental health treatment, which all require an additional release). 

I may revoke my consent in writing except to the extent that the Practice has already made disclosures in reliance upon my prior consent. I understand that if I do not sign this consent, or later revoke it, RTC Pediatrics may decline to provide treatment to me/my child(ren). 

In accordance with our Financial Policy, patient balances are due within 30 days after insurance pays. If your insurance plan is subject to routine deductibles and coinsurance, we require you to keep a credit card on file so we can collect those charges as soon as your insurance carrier designates your financial responsibility for the claim. We will only charge your credit card without prior notice if the claim was adjudicated normally. If your credit card on file expires or otherwise becomes uncollectable, we will expect you to promptly provide a new means of payment. 

Please enter the cardholder's name and contact information associated with the card you will swipe at the Front Desk. 

By signing below, I agree to RTC Pediatrics Credit Card on File policy, and I authorize RTC Pediatrics to keep my signature and valid credit/debit card number securely and confidentially on file.