Patient Forms

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Patient Information Sheet

Consent To Treat Form

Family History Form

Authorization to Release Medical Forms

Appointments

• A parent or legal guardian must accompany all patients.
• Our office sees patients based on an appointment system; we find that this is the most efficient way to provide service to our patients.
• If you intend to have more than one child seen, please specify that when calling so that we may allot the necessary amount of time.
• Unscheduled visits are discouraged except in cases of true emergencies. Therefore we ask that you call for an appointment before you bring your child to our office.
• During a sick-child visit, we limit our counseling to the current illness.
• Please plan to arrive at least 15 minutes early for your appointments. Late arrivals cause delays the rest of the day.
• If you arrive late you may be asked to reschedule.
• We prefer twenty-four hours’ notice if you are unable to keep your appointment.
• Sometimes, delays with emergencies may cause us to fall behind schedule. We are providing the best possible care on an individual basis and these delays are sometimes unavoidable. We respect the value of your time and will do everything possible to maintain our schedule.
• If a patient does not show up for a check-up appointment, a missed appointment fee of $50 will be charged to your account.

Prescriptions

• For prescription refills of non-controlled drugs, please contact your pharmacy.  Your pharmacy will then forward the request to us electronically.  There is no need to call us for routine refills. 
• If your refill or request requires that you contact us directly, we ask for a 48 hour notice. 
• Prescriptions refills are issued Monday through Friday between the hours of 9:00 AM and 4:30 PM only.
• When placing your call, please have your prescription and the telephone number of your pharmacy available.
• If your child has not been seen in the office for a period of time, we may require an examination before renewing the prescription.

Our Phone System

• If you have a life-threatening emergency, please call 911.
• We experience a very high volume of calls Monday through Friday between the hours of 8 AM and 10 AM and 1 PM and 2 PM.  In an effort to reduce long hold times, if your call is not of an urgent nature and if you are not calling for a sick appointment, please try not to call during these peak hours.
• When calling 791-2680 you will reach staff at the Mechanicsburg office.
• For sick or injury appointments, or to speak with a nurse, press 1.
• For routine physicals or to change an existing appointment, press 2.
• For billing inquiries, press 3.
• For insurance referrals, press 4.
• For prescription refills, which will be processed Monday through Friday 9 AM to 4:00 PM, press 5.

Emergencies and Urgent Problems

• Our telephones are answered twenty-four hours a day, seven days a week.
• During business hours, the staff in the office will answer the telephones.
• When the office is closed and you have an urgent problem or emergency, your call will be handled by our answering service.
• You will always dial 791-2680 to reach us regardless of the time of day.
• There is a fee for evening triage calls after 10 pm Monday through Saturday and after 8 pm on Sunday.
• In order to provide weekend and holiday services, we have formed Pediatric Acute Care Service with another local pediatric practice.  On Saturdays from 1 PM to 7 PM and Sundays and limited holidays from 11 AM to 5 PM, a pediatrician and medical assistant are available at our practice locations in Harrisburg and Camp Hill to provide care for acute problems.
• You can reach Pediatric Acute Care Service (PACS) at 909-1910. When you call, our medical assistant will direct you to the appropriate office location.
• If you need URGENT medical advice overnight (between the hours of 10 PM and 8 AM Monday through Saturday and 8 PM and 8 AM on Sunday), you are welcome to call our office. You will reach our nurse triage service and a nurse will evaluate your URGENT call and refer you to our physician on call if necessary. Because JDC is charged for each call made to this service, a charge of $20.00 per call will be added to your account.

Physicals and Forms – Driver, Sports, Daycare, Camp, Working Papers, etc.

• All physicals are scheduled at least 6 to 8 weeks in advance.
• If you know that your child will require an upcoming physical or a form completed, please contact us as soon as possible.
• It’s not too early to schedule physicals for the upcoming season, especially if you know your child will be going to camp, daycare, or will soon be driving.
• Our physicians conduct full well-child check-up physicals for camp, sports, school, daycare and driver permits.
• Please bring your forms with you to your appointment; if we need to complete a form at any other time than at a scheduled check-up, there is a $10 fee.
• Depending on the requirements of the form, an appointment with a nurse may be all that is necessary.

Insurance Information Regarding Physicals

• We follow AAP guidelines and recommend yearly checkups for patients two years of age and older.
• Please check with your insurance if you have any questions regarding coverage for childhood physicals.
• Many insurance companies require a full year (365 days) between visits for children 2 and up; others may cover one per calendar year, or one at any given age or age range (i.e. no more than one at age 6, one at age 7, etc. or one for ages 5-7, 8-10, etc.). Insurance plans differ depending on the employer, so if you are not sure what your coverage is, we will schedule your child at least one year from their last physical.

Fees and Insurance

• Please bring your insurance card to every appointment.
• Financial Agreement

Participating Insurance Plans

AETNA

Highmark Blue Shield

Capital Blue Cross

Geisinger

Health America/Health Assurance

Intergroup

Primesource

United Healthcare

Referrals and Prior Authorization

• If your health insurance requires pre-approval and/or referrals for certain services, we request a minimum of three business days’ notice.
• Please call our Insurance Referral Coordinator from 8:30 AM to 12:00 PM and 1:00 PM to 4:30 PM Monday through Friday at 791-2680 and choose option four.
• Please leave a message if she is not available.

Questions?

• If you have any questions about your account, please call our billing office between the hours of 9:00 AM and 4:00 PM Monday through Friday at 791-2680 and choose option three.
• If you reach the billing office voice mail, please leave a message and your call will be returned.