If you make an appointment for your child and do not keep it, you will be billed a $25 NO CALL, NO SHOW FEE. However, if you cancel 24 hours prior to your child’s appointment you will NOT be charged. If you are a Medicaid patient, NO SHOWS will be reported to your insurance.

This policy applies to new and established patients and will be charged directly to the parent/guarantor, NOT to the patient’s insurance. NO SHOW fees MUST be paid prior to the next visit.

As a courtesy, an appointment reminder will be texted to you approximately one business day prior to your scheduled appointment. It is the parent’s responsibility to keep the appointment that they have made regardless of whether they receive the courtesy text or not. Please keep in mind that you must update your cell phone number and email in order to receive the notification.

Timber Creek Pediatrics is a private owned clinic and we reserve the right to terminate the doctor-patient relationship of established patients due to NO SHOWS.

1. LAB & X-RAY RESULTS – $1 per page
2. LOST SCRIPTS – $10
3. WIC FORMS – $5
4. BLUE & YELLOW FORMS – $5 each (Blue & yellow forms will be available after 3 business working days)
5. SPORTS PHYSICAL – $20
6. SUMMER CAMPS – $20
7. BOY / GIRL SCOUT CAMP – $20
8. DISABILITY PAPERWORK – $15
9. LETTERS REQUESTED – $25
10. HANDICAP FORMS – $15
11. FMLA FORMS – $40
12. MEDICAL RECORDS – $1 first 25 pages, and .25 cents for any additional pages.
13. NOTARIZING DOCUMENTS – $10
14. SPORTS EKG –  $20
15. IN-OFFICE CONVENIENCE BLOOD DRAW – $20
16. COLLEGE/UNIVERSITY FORMS – $10
17. BLOOD TYPE ONLY – $25
18. INSURANCE COVERED LABS ONLY – $20
19. INSURANCE COVERED LABS & BLOOD TYPE – $35
20. DRUG TESTING – $10

(ALL OTHER FORMS WILL BE PRICED AT MANAGEMENTS DISCRETION)

Timber Creek Pediatrics adheres and complies with all recommendations and mandates set forth from the Centers of Disease Control and Prevention and the American Academy of Pediatrics in regards to immunizations and vaccinations.

We advise all of our patients to comply with the age appropriate immunizations and vaccination schedules established and set forth by the CDC and the American Academy of Pediatrics. However, patients who have adamant dissenting reasons and elect not to comply with these recommendations, will be advised to contact the local Health Department and obtain a Religious and or Medical Exemptions. Upon receipt of the documented exemption form in our office, our staff will scan the document into the patient’s chart within our electronic medical record system as proof. Rest assure, we will still be more than willing to treat your child, however without the proper documentation in place we will be unable to do so. In addition, our office can offer immunization catch up schedules if a patient decides to move in a different direction at a future point in time.

All patients who elect not to vaccinate their child with all recommended immunizations including the Flu Shot, will be required to sign a refusal form that will be scanned and entered into their electronic medical record for proof. We respect the decisions of our patients and will be more than willing to answer any questions or doubts you may experience in regards to this matter.

 

Thank you for entrusting our office with all of your child’s healthcare needs and well-being.
TCP Management

 

Effective 4/16/2016

TIMBER CREEK PEDIATRICS
___________________________
15212 East Colonial Drive,
ORLANDO, FL 32826

 

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

We are required by law to provide you with this notice that explains our privacy practices with regard to your medical information and how we may use and disclose your protected health information for treatment, payment, and for health care operations, as well as for other purposes that are permitted or required by law. You have certain rights regarding the privacy of your protected health information and we also describe them in this notice.

 

Ways in Which We May Use and Disclose Your Protected Health Information:

The following paragraphs describe different ways that we use and disclose your protected health information. We have provided an example for each category, but these examples are not meant to be exhaustive. We assure you that all of the ways we are permitted to use and disclose your health information fall within one of these categories.

Treatment. We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. We will also disclose your health information to other physicians who may be treating you. Additionally we may from time to time disclose your health information to another physician whom we have requested to be involved in your care. For example – we would disclose your health information to a specialist to whom we have referred you for a diagnosis to help in your treatment.

Payment. We will use and disclose your protected health information to obtain payment for the health care services we provide you. For example – we may include information with a bill to a third-party payer that identifies you, your diagnosis, procedures performed, and supplies used in rendering the service.

Health Care Operations. We will use and disclose your protected health information to support the business activities of our practice. For example – we may use medical information about you to review and evaluate our treatment and services or to evaluate our staff’s performance while caring for you. In addition, we may disclose your health information to third party business associates who perform billing, consulting, or transcription services for

 

Other Ways We May Use and Disclose Your Protected Health Information:

Appointment Reminders. We will use and disclose your protected health information to contact you as a reminder about scheduled appointments or treatment.

Treatment Alternatives. We will use and disclose your protected health information to tell you about or to recommend possible alternative treatments or options that may be of interest to you.

Others Involved in Your Care. We will use and disclose your protected health information to a family member, a relative, a close friend, or any other person you identify that is involved in your medical care or payment for care.

Research. We will use and disclose your protected health information to researchers provided the research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

As Required by Law. We will use and disclose your protected health information when required to by federal, state, or local law. You will be notified of any such disclosures.

To Avert a Serious Threat to Public Health or Safety. We will use and disclose your protected health information to a public health authority that is permitted to collect or receive the information for the purpose of controlling disease, injury, or disability. If directed by that health authority, we will also disclose your health information to a foreign government agency that is collaborating with the public health authority.

Worker’s Compensation. We will use and disclose your protected health information for worker’s compensation or similar programs that provide benefits for work-related injuries or illness.

Inmates. We will use and disclose your protected health information to a correctional institution or law enforcement official if you are an inmate of that correctional institution or under the custody of the law enforcement official. This information would be necessary for the institution to provide you with health care; to protect the health and safety of others; or for the safety and security of the correctional institution.

 

Your Health Information Rights

Although your health record is the physical property of the health care practitioner or facility that compiled it, the information belongs to you. You have the right to:

A Paper Copy of This Notice. You have the right to receive a paper copy of this notice upon request. You may obtain a copy by asking our receptionist at your next visit or by calling and asking us to mail you a copy.

Inspect and Copy. You have the right to inspect and copy the protected health information that we maintain about you in our designated record set for as long as we maintain that information. This designated record set includes your medical and billing records, as well as any other records we use for making decisions about you. Any psychotherapy notes that may have been included in records we received about you are not available for your inspection or copying by law. We may charge you a fee for the costs of copying, mailing, or other supplies used in fulfilling your request.

If you wish to inspect or copy your medical information, you must submit your request in writing to Practice Manager c/o Timber Creek Pediatrics, 15212 East Colonial Drive, Orlando, FL 32826. You may mail in your request, or bring it to our office. We will have 30 days to respond to your request for information that we maintain at our practice site. If the information is stored off-site, we are allowed up to 60 days to respond but must inform you of this delay.

Request Amendment. You have the right to request that we amend your medical information if you feel that it is incomplete or inaccurate. You must make this request in writing to our practice manager, stating exactly what information is incomplete or inaccurate and your reasoning that supports your request.

We are permitted to deny your request if it is not in writing or does not include a reason to support the request. We may also deny your request if:

• the information was not created by us, or the person who created it is no longer available to make the amendment;
• the information is not part of the record which you are permitted to inspect and copy;
• the information is not part of the designated record set kept by this practice; or if it is the opinion of the health care provider that the information is accurate and complete.

Request Restrictions. You have the right to request a restriction or limitation of how we use or disclose your medical information for treatment, payment, or health care operations. For example – you could request that we not disclose information about a prior treatment to a family member or friend who may be involved in your care or payment for care. Your request must be made in writing to our practice manager.

We are not required to agree to your request if we feel it is in your best interest to use or disclose that information. However, if we do agree, we will comply with your request unless that information is needed for emergency treatment.

An Accounting of Disclosures. You have the right to request a list of the disclosures of your health information we have made outside of our practice that were not for treatment, payment, or health care operations. Your request must be made in writing and must state the time period for the requested information. You may not request information for any dates prior to April 14, 2003 (the compliance date for the federal regulation) or for a period of time greater than six years (our legal obligation to retain information).

Your first request for a list of disclosures within a 12-month period will be free. If you request an additional list within 12-months of the first request, we may charge you a fee for the costs of providing the subsequent list. We will notify you of such costs and afford you the opportunity to withdraw your request before any costs are incurred.

Request Confidential Communications. You have the right to request how we communicate with you to preserve your privacy. For example – you may request that we call you only at your work number, or by mail at a special address or postal box. Your request must be made in writing and must specify how or where we are to contact you. We will accommodate all reasonable requests.

File a Complaint. If you believe we have violated your medical information privacy rights, you have the right to file a complaint with our practice manager or directly to the Secretary of Health and Human Services.

To file a complaint with our manager, you must make it in writing within 180 days of the suspected violation. Provide as much detail as you can about the suspected violation and send it to Practice Manager c/o Timber Creek Pediatrics, 15212 East Colonial Drive, Orlando, FL 32826. You should know that there would be no retaliation for your filing a complaint.

 

Uses or Disclosures Not Covered

Uses or disclosures of your health information not covered by this notice or the laws that apply to us may only be made with your written authorization. You may revoke such authorization in writing at any time and we will no longer disclose health information about you for the reasons stated in your written authorization. Disclosures made in reliance on the authorization prior to the revocation are not affected by the revocation.

 

For More Information

If you have questions or would like additional information, you may contact our practice manager at 407-380-1777.

 

Effective Date: 01/01/03

As a courtesy to our patients, we participate in many health care insurance programs. Insurance is considered a method of reimbursing the patient for professional services fees paid to the doctor and is not substitute for your responsibility of payment for services provided.

 

• As the patient, it is your responsibility and obligation to understand your health insurance policy benefits and obligations, this includes your financial obligations for the services provided, by the participating physician, and to obtain prior authorization when necessary.
• Health care regulations require the collection of all co-payments, deductibles, balances and non-covered professional fees at the time of the service. It is your responsibility to pay the deductible amount, co-insurance, or any other balance not paid by your insurance company.
• If your insurance company does not pay for professional services within a reasonable time period, we have the right to bill you for the balance on your account.
• All co-payments are collected at the time that you receive services. Insurance co-payments are collected at every visit.
• Some insurance companies only pay a portion of the professional fees (fixed allowances or percentages). Depending on your plan, you may be required to pay any outstanding balance on your account.

The office of Timber Creek Pediatrics encourages all patients to schedule appointments prior to arriving to our office. However, we do understand and acknowledge that unexpected medical circumstances may arise that are beyond one’s control that warrant immediate medical attention. Walk-ins are accepted on a case by case basis. Walk-ins are welcomed and accommodated into the schedule depending on the severity of the chief complaint and or reason for the visit (ex: sick or well visit.) Furthermore, walk-ins do cause a disruption in our schedule and we strive to the upmost of our ability to welcome all walk-ins with the soonest appointment pending availability. Please be advised that scheduled appointments take precedence over non urgent walk-ins. We gladly appreciate your cooperation and understanding. If you have any questions or concerns regarding this matter, please do not hesitate to ask our staff for further clarification.

Thank you

We provide an easily accessible alternative for school and sports physicals to help keep children safe and strong!

• Height and weight
• Blood pressure
• Eating and sleeping habits
• Heart rate, lung function
• Musculoskeletal issues
• Vital signs
• Ears and throat
• Allergies, skin issues, and nutrition
• Review of all medications and medical history
• Physical exam

The patient has the right to treatment without discrimination as to race, age, religion, sex, national origin, socioeconomic status, sexual orientation, gender identity or expression, disability, veteran status, or source of payment. You will be treated with dignity, compassion, and respect as an individual.