Our Office Policies & Forms | Cancellation & Insurance Info

Prairie Pediatrics

Office Policies & Forms


Cancellation & Late Arrival Policy

 In respect of the time and schedules of our staff and your fellow patients, if you cannot make an appointment, please cancel at least 24 hours in advance.   Also, to ensure we have sufficient time to care for your child, please arrive at least 5 minutes prior to your appointment time to get checked in.  

The first time you cancel with less than 24 hours notice or arrive more than 5 minutes late to your appointment, you will be reminded of our policy.  A second time may result in a missed appointment fee.  A third incident will lead to your possible dismissal from the practice.

Patient Rights & Responsibilities

Thank you for trusting us with your child's healthcare.  I strive to provide care that is exemplary in quality and compassionate in delivery.  In treating your child, we follow guidelines set up by the American Academy of Pediatrics and deliver evidence based recommendations.  As a parent or patient, you have the right to hear options for your care along with my professional assessment and advice. 

We practice shared decision making whenever possible and provide care in a developmentally appropriate way.  In order to help your child, you agree to provide accurate information about their health, including their medications, allergies, past medical history, family medical history and social history

Financial Policies

Insurance Info: If you are enrolled in a health insurance please, please provide us with complete and accurate info before your appointment and we will bill your plan for covered services.  Click here to see list of insurances currently accepted by our practice.

Insurance Coverage: We suggest you review the terms of your insurance coverage thoroughly to understand what is covered before care is provided.  Payment for non-covered services or denied claims will be your responsibility.   Please be aware that we may provide services that your insurance may deny as "not covered."    If you have questions about coverage, please contact your insurance company.  We are not responsible for knowing your coverage details. 

Co-Pays & Fees: Co-pays are due at the time of visit and may not be waived for any reason.  Prompt payment for service not covered by insurance, including deductibles, is expected.  There is a $25 fee for  invalid checks. 

After Hours Care: Evening (after 5pm), weekend and holiday visits (includes all federal holidays) have a $30 surcharge. Check with your insurance plan if you questions about your coverage.  

PCP Designation: If your insurance requires that a Primary Care Physician be designated, you must name our practice as  the PCP prior to your visit.  Failure to do so may result in denial of coverage and charges for your visit that you will be responsible for.

Well Care Scope Limitations: If issues are raised during a well care visit that need to be addressed which are not covered under insurance guidelines for a well care visit, your insurance will be billed for an additional "sick" visit.  We choose to do this rather than ask patients to schedule a future follow-up visit.  This approach addresses the patient’s needs sooner and saves the caregiver both time and money.  The charges for an add-on sick visit are typically lower than a stand-alone sick visit. This benefits patients in case insurance assigns the charges to a patient's deductible or does not cover the visit

Form Return Process and Form Repository

Prior to your scheduled visit, you will receive any required forms via text through the Spruce app and you can access them below.

Completing and returning forms via Spruce prior to your appointment will save time during your visit and allow us to be fully prepared to care for you child's needs.    

Forms can be printed, completed and then texted back using Spruce by scanning or taking a picture of all pages of your completed forms. 

Download Spruce

General Forms:

Developmental Questionnaires for Well Visits:

Vaccination Policy

Vaccines are lifesaving and safe.  We follow the vaccination schedule published by the Center for Disease Control. 

In consideration for the health of your fellow patients and community members, we require all patients to be up to date on their vaccinations. 

Failure to adhere to the vaccination schedule resulting in delays of 6- 12 months will result in dismissal from the practice.

Privacy Policy

We are dedicated to the protection of your family's personal data, that's why Prairie Pediatrics has adopted a formal policy on Patient Privacy Practices (linked below) and ensures all staff are fully trained on HIPAA requirements and our office's HIPAA compliant policies and processes. 

Our Patient Privacy Practices policy fully describes the rights and control you have over your data, the protections provided to your children regarding their personal medical information and how your data will and will not be used.