New patient HOTV

Dear Parent or Guardian,

Welcome to Heart of the Valley Pediatrics! We're so glad you're here. Thank you for trusting us with your child's care. Whether you're expecting your first baby, transitioning from another practice, or navigating a new health concern, we want you to feel confident, supported, and heard every step of the way.

At Heart of the Valley Pediatrics, our mission is to provide compassionate, evidence-based care in a warm, welcoming environment. We strive to listen carefully, act thoughtfully, and serve each family with excellence, honoring the trust placed in us as both caregivers and stewards of a higher calling.

We are a team of experienced pediatric providers who consider it a privilege to walk alongside families as their children grow. From well visits and developmental milestones to the inevitable bumps, fevers, and worries, we are here to support you with clinical excellence, timely communication, and a kind, listening ear.

Please take a few minutes to complete this New Patient Packet so we can get to know your child and family better. We look forward to meeting you soon and are honored to be part of your child's health journey.

Warmly,
The Heart of the Valley Pediatrics Team

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heartofthevalleypediatrics.com

Our Commitment to Your Privacy

At Heart of the Valley Pediatrics, we understand that your child's health information is personal. We are committed to protecting your privacy and maintaining the confidentiality of your child's medical information as required by law.
This Notice describes how we may use and disclose medical information about your child and how you can access this information.

Our Uses and Disclosures
- For payment: To bill your insurance or send you statements for services provided.
- For healthcare operations: To manage and improve our practice, train staff, or conduct quality assessments.
- For public health and safety: To report vaccine records, infectious diseases, abuse or neglect, or threats to health or safety as required by law.
- With your authorization: You must give written permission for us to share information for purposes not listed above, such as with schools, camps, or certain family members. You may revoke authorization at any time in writing.
Your Rights: You have the right to:
- Get a copy of your child's medical record
- Request corrections to the record if you believe something is incorrect or incomplete
- Request confidential communications (e.g., to a different address or phone)
- Ask us to limit what we share (e.g., with certain family members)
- Get a list of people or organizations we've shared information with
- Receive a paper or electronic copy of this notice at any time
To exercise any of these rights, please contact our office in writing.

Our Responsibilities
- We are required by law to keep your child's health information private.
- We will let you know promptly if a breach occurs that may compromise your child's privacy.
- We will not use or share your information except as described here unless you give us written permission.
Changes to This Notice
We may change this notice at any time. The new version will apply to all health information we hold and will be posted in our office and on our website.

Questions or Complaints?

If you have questions, or if you believe your child's privacy rights have been violated, you may contact:

We may use and share your child's health information:

Heart of the Valley Pediatrics
Phone: 256-242-6443
Address: 1225 13th Avenue SE, Decatur AL, 35601.

For treatment: To provide and coordinate medical care with other providers, specialists, or therapists.

You may also file a complaint with the U.S. Department of Health & Human Services. We will not retaliate against you for filing a complaint.

Are you a new patient to Dr. Smith or Dr. Ingram?
Section 1: Patient Demographics & Contact Information
Child's Full Name*
Date of Birth*

MonthDayYear
Date
MaleFemale
Preferred Name/Nickname?
Primary Address (Child's Residence):
Street*
City*
State*
Zip*
Parent/Guardian 1 Name*
Phone number*
Format: (000) 000-0000.
Relationship to Child*
Email Address
example@example.com
Preferred method for appointment reminder*
Parent/Guardian 2 Name
Relationship to Child
Lives at same Address as Parent/Guardian 1?
Street
SKIP if same as parent/guardian 1
City
SKIP if same as parent/guardian 1
State
SKIP if same as parent/guardian 1
Zip
SKIP if same as parent/guardian 1
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Marital Status of Parents/Guardians:*
Legal Custody Information (If applicable):
If yes, please briefly describe and/or provide appropriate documentation
Additional Contact Information:
Emergency Contact (Other than Parent/Guardian): *
Name
Relationship to Child*
Phone Number*
Format: (000) 000-0000.

Add Siblings (including step or half siblings)

Rows	Name	DOB	Relationship	Lives in Household?
1
2
3
4
5

Any other household members? Iinclude name/relationship)
Primary Language Spoken at Home
Preferred Pharmacy:
Pharmacy Name*
Pharmacy Location/Address or Intersection

Section 2: Insurance & Billing Information
Insurance Provider*
Member ID*
Group #*
Policyholders Name*
Policyholder's Date of Birth*

MonthDayYear
Date
Policyholder's relationship to patient*
Secondary Insurance Provider (if applicable)
if not applicable, skip to next section
Employer (if applicable)
Secondary Insurance Member ID
Secondary Insurance Group #
Secondary Insurance Policyholders Name
Secondary Insurance Policyholder Date of Birth

MonthDayYear
Date
Responsible Party for Billing*
Relationship to Child (if not listed above)
Phone Number (if not listed above)
Format: (000) 000-0000.

Billing and Financial Policy

At Heart of the Valley Pediatrics, we strive to make the billing process as clear and simple as possible. We are committed to working with families to ensure timely and fair payment for the care your child receives.

Insurance: We will file claims with your insurance provider. Please bring your most recent insurance card to every visit. It is your responsibility to ensure that your child is covered on the date of service and to notify us of any changes.

Co-pays and deductibles: Co-pays, co-insurance, and deductibles are due at the time of service. If these are not paid at check-in, your appointment may be rescheduled.

Non-covered services: You are responsible for any services not covered by your insurance. We will make every effort to inform you of these charges ahead of time.

Statements & balances: You will receive a statement if a balance is due after insurance has processed the claim. Payment is due within 30 days of the statement date unless other arrangements have been made.

Delinquent accounts: Accounts unpaid after 90 days may be referred to a collection agency. If this occurs, continued care may be suspended until the account is resolved.

Missed appointments: We ask for at least 24 hours' notice if you need to cancel. Repeated missed appointments may result in a fee or dismissal from the practice.
Printed Name*
I have read and agree to the above financial and billing policies. I authorize the release of medical information necessary to process claims and the payment of medical benefits directly to Heart of the Valley Pediatrics. Signature of Responsible Party*

Consent for treatment

I authorize the providers and staff at Heart of the Valley Pediatrics to evaluate and treat my child. This includes routine check-ups, immunizations, diagnostic procedures, and medical treatment as needed.

I understand that:
- I may ask questions about any treatment
- I may revoke this consent in writing at any time
Childs Full Name*
Parent/Guardian Name printed*
Signature*
HIPAA Privacy Acknowledgment

I acknowledge that I have received or been offered the Notice of Privacy Practices for Heart of the Valley Pediatrics. I understand it explains how my child's health information may be used or disclosed and that I may request a copy at any time.

I received and reviewed the Notice of Privacy Practices. I declined a printed copy but understand it is available upon request. A full copy of our HIPAA Notice of Privacy Practices is included in this packet as above.
Parent/Guardian Name printed*
Signature*
Telehealth Consent

I consent to my child receiving medical care via telehealth when appropriate. This may include video visits, phone consultations, or secure messaging.I understand that the risks, benefits, and limitations of telehealth have been explained.Telehealth is optional and can be declined at any time. All visits will remain private and complywith HIPAA regulations.
Signature
Consent for Others to Accompany My Child
I authorize the following individuals (list them below) to bring my child to appointments and to make medical decisions in my absence:

This consent remains valid until / revoke it in writing
First Name Last Name Relationship to Child Area Code Phone Number
First Name Last Name Relationship to Child Area Code Phone Number
Authorization to Share Medical Information

I authorize Heart of the Valley Pediatrics to share relevant medical information about my childwith the following individuals (e.g., grandparents, step-parents, other caregivers):
First Name Last Name Relationship to Child Area Code Phone Number
First Name Last Name Relationship to Child Area Code Phone Number
I authorize full access to all medical records and communicationsI authorize access only to appointment and immunization history
Signature*

7. Office Policies & Acknowledgement
1. Appointments & Cancellations

No Show Policy

At Heart of the Valley Pediatrics, missed appointments limit our ability to care for all our patients. Please help us serve your family and others by keeping scheduled appointments or giving at least 24 hours’ notice if you need to cancel.

What is considered a “No Show”?
- A patient missing a scheduled appointment without, at a minimum, a twenty-four (24) hour cancellation or rescheduling notice.
- Any appointment that is scheduled on the same date of service (sick visit) that is not cancelled within 1-hour prior to appointment time.
- Any late arrival of 15 minutes or more and the patient is consequently unable to be seen.
We may exact any of the following penalties for patients with a no-show history:
- Two or More No-Shows: Appointment times may be limited to the end of the morning or end of the day.
- Chronic No-Shows: Families with repeated no-shows may be scheduled in shared appointment slots (double-booked).
- Practice Dismissal: The practice reserves the right to dismiss patients who fail to keep scheduled appointments. If there are three or more No-Shows in a 12 month period for any member of the same family, this may result in a discharge of the family from the practice.
We ask that you cancel your appointment upon your receipt of the reminder notification or contact our office 24 hours prior to your appointment to cancel or reschedule your appointment to avoid these No-Show penalties.

Keeping appointments is heavily dependent upon us having up-to-date contact information. If your phone number, email address, or physical address change, please notify our office as soon as possible to make sure your reminders are able to reach you.

We thank you for your cooperation and understanding. Please print and sign below as your acknowledgement that you have read and agreed to this policy.
Signature
2. Communication:
We offer multiple ways to connect with our office:
Routine messages may be sent through our patient portal, by phone, or via secure text (Review our text policy on the website)
We do not offer medical advice by email or social media.
After-hours calls will be routed to our nurse line or on-call provider as available.
Urgent or life-threatening concerns should go directly to 911 or the nearest ER.

3. Vaccine Policy

We follow the CDC and AAP recommended immunization schedule and believe vaccines are an essential part of keeping your child and community healthy.

We are a vaccine-supportive practice, and we require children receive, at a minimum, the vaccines required for school entry in Alabama.
We will consider a pre-approved alternate schedule, however we do require initiation of vaccines by 4 months of age.

4. Forms & Records
Most school, camp, or daycare forms can be completed within 3–5 business days.
Immunization records and growth charts are available through the patient portal.
There may be a small fee for multiple or expedited form requests.
If your child has been seen for a physical in the last calendar year, we are able to complete a school or sports form, otherwise they will need to be scheduled for a visit. Please note, we charge a $30 fee for routine sports physicals done outside of scheduled well visits.

5. Insurance & Payments
Please bring your insurance card to each visit.
Co-pays and outstanding balances are due at the time of service.
It is your responsibility to notify us of any insurance changes.

6. Respectful Environment
We are committed to maintaining a kind, inclusive, and respectful space for all families and staff. Any threatening or inappropriate behavior may result in termination of care. To maintain the privacy of our patients, there should be no video or voice recording in our office.

7. Refill/Referral Requests

Please allow 3 working days for refill requests to be processed. Please remind us about any refill requests at your visits.
Please allow up to 2 weeks for non-urgent referral requests.
Child's Name*
Parent/Guardian Name printed*
Signature*

Date

MonthDayYear
Date
Printed Name of Patient's Representative if applicable
Representative's Relationship to Patient if applicable

Friend/FamilyOB or HospitalOnline SearchSocial MediaOther
YesNo
What made you choose Heart of the Valley Pediatrics for your child's care?
Any suggestions for improving the new patient experience?
Should be Empty:

7. Office Policies & Acknowledgement